SINGLE PATIENT LEDGER Thomas J. Magnani, D.D.S. Date: 04/18/2019 Page: 1 Patient Name: 9 East 71st Street New York, NY 10021 Chart Number. Billing Type: 1 DATE TEETH DESCRIPTION PATIENT CHARGE PAYMENT BALANCE 02/18/2019 Patient Balance Forward 0.00 0.00 02/19/2019 Prophylaxis-adult 180.00 180.00 02/19/2019 Periodic oral evaluation 40.00 220.00 02/21/2019 Whitening Gel 22% 65.00 285.00 02/21/2019 3 Amalgam-2 surf. 450.00 735.00 02/21/2019 4 Resin composite-1s, posterior 425.00 1160.00 TOTAL PATIENT BALANCE AS OF 0411812019: 1160.00 EFTA00316502