Speech and Language Evaluation (includes hearing screening) Speech and Language Therapy: Regular Semester (Fail or Spring; 2x week 12 weeks) Summer Session (2 week - 6 weeks) ROBERT G. COMBS GROUP Regular Semester (Fail or Spring; 2x week 12 weeks) Summer Session (2 week - 6 weeks) COMBINED THERAPY and GROUP Fail or Spring Semesters Summer Session Accent Modi?cation Program I: Additional Services: INVOICE Please make checks payable to University of Missouri OF AMOUNT SERVICE SERVICE FEE PAYMENT DATE PAID DUE Speech/ Linguag: Spring 2017 Paid in Full eraPY 765.00 765. - - Robert G. 00 2 9 17 Combs Language Preschool These fees are due and payable on the first day of Clinic unless prior arrangements have been made. Thank you. Speech and Language Evaluation (includes hearing screening) CID Speech and Language Therapy: Regular Semester (Fall or Spring; 2x week 12 weeks) Summer Session (2 week - 6 weeks) ROBERT G. COMBS GROUP Regular Semester (Fall or Spring; 2x week 12 weeks) Summer Session (2 week - 6 weeks) COMBINED THERAPY and GROUP Fall or Spring Semesters Summer Session Accent Modi?cation Program Additional Services: INVOICE Please make checks payable to University of Missouri SERVICE OF AMOUNT SERVICE FEE PAYMENT DATE PAID DUE Speech/ Language FALL 2016 765.0 - - Therapy 0 $76500 9/23/16 Pald In Robert G. Combs Language Preschool These fees are due and payable on the first day of Clinic unless prior arrangements have been made. Thank you. STATEMENT OF SERVICES Date of CPT Provider Description ICD-10 Charge Balance Service Code Code 02/20/17 92526 ?3 Treatment R13.11 70.00 70-00 - of M5. swallowing dysfunction and or oral functioning for feeding Private pay ?20.00 50.00 adjustment TOTAL 50.00 Patient Name Amount Due Due Date 50.00 02/20/2017 EXPLANATION OF BENEFITS 2 Date of CPT Provider Description Charge Balance 3 Service Code 10 Code 9 02/08/2017 97166 E23. Occupational [227.80 80.00 80.00 Therapy 0T Evaluation 97535 Treatment for self- care] home management A?owable -10.00 70.00- TOTAL $70-00 . Patient Name Amount Due Due Date - $70.00 02/08] 2017 STATEMENT OF SERVICES Date of CPT Provider Description ICD-10 Charge Balance Service Code Code 02/15/2017 92610 Evaluation R13.11 200.00 200.00 of oral soft M.S. tissue and muscle function 92522 Evaluation R4189 150.00 350.00 ofspeech Private pay -200.00 150.00 adjustment TOTAL 150.00 I Patient Name Amount Due Due Date 150-00 02/15/2912,,? 7 AT A GLANCE PLAN DISCOUNT YOUR PLAN PAID YOUR RESPONSIBILITY DEDUCTIBLE: AMOUNT BILLED PLAN DISCOUNTS YOUR PLAN PAID 04/14/2016 Physica! therapy $353.00 $0.00 $157.00 $157.00 YOUR RESPONSIBILITY $157.00 YOU MAY OWE $157.00 PAYMENT HELP DEDUCTIBLE YOUR RESPONSIBILITY I We? IS a- ?arm-Jeevmri' .- 9V4.