P.O. BOX 14079LEXINGTON KY 40512-4079USA

Payment Address:

Provider Address:

Explanation Of BenefitsPlease Retain for Future Reference

Printed:Page:

PIN:TIN:Trace Number:Trace Amount:

07/07/20142 of 5

Notes:Update your address, telephone number, e-mail address and/or NPI information by visiting our website.

Patient Name:Claim ID:Member: DIAG: 780.79, 244.9, 627.2

Group Number: 0883610-12-610 C P6<)%0Group Name: LOCKHEED MARTIN CORPORATIONProduct: Aexcel® Plus Aetna Choice® POS II Aetna HealthFund®Aetna Life Insurance Company

Network ID: 00393 AETNA CHOICE POS II

Recd: 06/26/14 Member ID: Patient Account: 39610123EFY0F81LM00

SERVICEDATES

PL SERVICECODE

NUMSYCS

NEGOTIATEDAMOUNT

COPAYAMOUNT

NOTPAYABLE

SEEREMARKS

DEDUCTIBLE COINSURANCE

PATIENTRESP

PAYABLEAMOUNT

SUBMITTEDCHARGES

06/17/14

06/17/14

06/17/14

06/17/14

06/17/14

06/17/14

11 9921425

93922

85025

84481

84443

84439

1.0 193.00 92.24

92.14

12.87

26.53

6.85

92.24

92.14

12.87

6.85

92.24

92.14

12.87

6.85

212.00

26.53

57.78

57.33

30.75

0.00

06/20/1406/20/1406/20/1406/20/14

11111111

96372J3415J3415J0288

1.01.01.01.0

60.0010.0010.0010.00

98.00 49.63

19.268.918.18

13.28

49.63

19.268.918.18

13.28

0.00

0.00

0.00

0.00

0.00

577.39 204.10 83.86 204.10 204.10 0.00

1.0

1

57.33 1

1.0

11

11

11

11

11

TOTALS

ISSUED AMT: $200.00

Fund Paid $200.00

$4.10

$200.00

Remarks:1 - The member’s plan provides coverage for charges that are reasonable and appropriate. The charge for this service does not meet this

requirement of the member’s plan of benefits because this service is rebundled into a more comprehensive procedure performed on the same date of service. Do not bill the member [U64]Your claim has been seperated to epidite handling. You will receive a seperate notice for the other services reported. (E73)

Total Patient Responsibility:

Claim Payment:

For Questions Regarding This Claim P.O. BOX 981106 EL PASO, TX 79998-1106CALL (888) 632-3862 FOR ASSISTANCE

Note: All inquiries should refernce the ID number above for prompt response.

Patient NameClaim ID:Member: DIAG: 780.79, 783.1

Group Number: 08351412-10-100 A P1*>Z0Group Name: DIGITAL INSURANCE, INC.Product: Aetna Choice® POS IICCAetna Life Insurance Company

Network ID: 00393 AETNA CHOICE POS II

Recd: 06/27/14 Member ID: Patient Account: 33907029E735FM21R00

SERVICEDATES

PL SERVICECODE

NUMSYCS

NEGOTIATEDAMOUNT

COPAYAMOUNT

NOTPAYABLE

SEEREMARKS

DEDUCTIBLE COINSURANCE

PATIENTRESP

PAYABLEAMOUNT

SUBMITTEDCHARGES

TOTALS

Continued on Next Page

P.O. BOX 14079LEXINGTON KY 40512-4079USA

Payment Address:

Provider Address:

Explanation Of BenefitsPlease Retain for Future Reference

Printed:Page:

PIN:TIN:Trace Number:Trace Amount:

07/07/20144 of 6

Patient Name:Claim ID:Member: DIAG: 780.79, 783.1

Group Number: 0701320-10-008 PB P1(\?0Group Name: E.I. DU PONT DE NEMOURS & COMPANYProduct: Aetna Choice® POS IIAetna Life Insurance Company

Network ID: 00393 AETNA CHOICE POS II

Recd: 06/20/14 Member ID: Patient Account: 37738447EXJLFKX600

SERVICEDATES

PL SERVICECODE

NUMSYCS

NEGOTIATEDAMOUNT

COPAYAMOUNT

NOTPAYABLE

SEEREMARKS

DEDUCTIBLE COINSURANCE

PATIENTRESP

PAYABLEAMOUNT

SUBMITTEDCHARGES

06/12/14

06/12/14

06/12/14

06/12/14

11 9921425

93922

85025

84481

1.0 60.00 19.26

5.91

8.18

13..28

10.00

10.00

18.00

15.41

7.13

6.54

10.62

3.85

1.78

1.64

2.66

3.85

1.78

1.64

2.66

98.00 49.63 9.939.93 39.70

1.0

1.0

1.0

11

11

11

TOTALS

ISSUED AMT: $39.70

$9.93

$39.70

Total Patient Responsibility:

Claim Payment:

For Questions Regarding This Claim P.O. BOX 981106 EL PASO, TX 79998-1106CALL (888) 632-3862 FOR ASSISTANCE

Note: All inquiries should refernce the ID number above for prompt response.

$30.60

$173.37

Total Patient Responsibility:

Claim Payment:

For Questions Regarding This Claim P.O. BOX 981106 EL PASO, TX 79998-1106CALL (888) 632-3862 FOR ASSISTANCE

Note: All inquiries should refernce the ID number above for prompt response.

Continued on Next Page

Patient Name:Claim ID:Member: DIAG: 401.1, 272.0, 783.1

Group Number: 0863205-11-100 B P1&EZ0Group Name: UNITED PARCEL SERVICE OF AMERICA, INC.Product: Aetna Choice® POS IIAetna Life Insurance Company

Network ID: 00393 AETNA CHOICE POS II

Recd: 06/20/14 Member ID: Patient Account: 37211120EYPBFJKX000

SERVICEDATES

PL SERVICECODE

NUMSYCS

NEGOTIATEDAMOUNT

COPAYAMOUNT

NOTPAYABLE

SEEREMARKS

DEDUCTIBLE COINSURANCE

PATIENTRESP

PAYABLEAMOUNT

SUBMITTEDCHARGES

06/12/14

06/12/14

06/12/14

06/12/14

06/12/14

06/12/14

11 9921325

96372

93922

J3415

J1955

J0288

1.0 128.00 62.20

19.26

92.14

8.18

8.91

13.28

60.00

212.00

10.00

10.00

10.00

52.87

16.37

78.32

7.57

6.95

11.29

9.33

2.89

13.82

1.34

1.23

1.99

438.00 203.97 204.10 30.60

9.33

2.89

13.82

1.34

1.23

1.99

30.60 173.37

1.0

1.0

11

11

11

11

11

TOTALS

ISSUED AMT: $173.37

Provider Explanation of Medical Bene�ts Report

Provider Number 582534426

Provider Name Date through which claims were processed 06/30/2014

THIS IS NOT A BILLRetain for Your Records

Page1

Line Procedure Date

Procedure Code

AdjustedProcedure

Code

BilledAmount

AdjustedProcedure Code

Amount

AllowedAmount

Not Covered/Discount

Deduct/CopayAmount

CoinsuranceAmount

DRG/Per Diem

Type

DRG/Per DiemNumber

DRG/Per DiemAmount

DRG/Per Diem

Bene�tAmount

PlanBene�t

SeeNote

Reminder: A coverage determination, prior authorization, or certi�cation that is made prior to a service being performed is not a promise to pay for the service at any particular rate or amount. �e patient’s summary plan description governs amount payable, as every claim submitted is subject to all plan provisions, including, but not limited to, eligibility requirements, exclusions, limitations, and applicable state mandates.

PATIENT NAME: PATIENT #: 33707950

SUBSCRIBER#: REF #: 7651417994260

OPERATION LACATION/GROUP # 35775-9-3213484 RECEIVE DATE: 06/28/2014 PROCESS DATE: 06/30

MEMBER NAME:

1

2

06192014 93000

06192014 93922

56.00

212.00

268.00

23.09

133.25

156.34

$156.34BALANCE . . . . . . . . . . . .

23.09

133.25

156.34

32.91

78.75

111.66TOTAL

0.00

0.00

0.00

0.00

0.00

0.00

0.00

A

A

$1,354,21 HAS BEEN APPLIED TOWARDS THE $3,000 IN NETWORK FAMILY DEDUCTIBLE FOR 2014$1,354,21 HAS BEEN APPLIED TOWARDS THE $6,000 IN NETWORK FAMILY ‘OUT OF POCKET LIMIT’ FOR 2014

**NOTES ON BENEFIT DETERMINATION:****THIS EXPENSE HAS BEEN APPLIED TO PLAN DEDUCTIBLE OR COPAYIF YOU HAVE ANY QUESTIONS REGARDING THIS CLAIM, PLEASE INCLUDE THEREFERENCE NUMBER ON INQUIRIES.

A) CUSTOMER: THANK YOU FOR USING CIGNA’S OPEN ACCESS PLUS NETWORK. THE DISCOUNT SHOWN IS HOW MUCH YOU SAVED. YOU DON’T NEED TO PAY THAT AMOUNT. IF YOU ALREADY PAID YOUR HEALTH CARE PROFESSIONAL MORE THAT THE “WHAT I OWE” AMOUNT, PLEASE ASK FOR A REFUND.HEALTH CARE PROFESSIONAL: YOUR CIGNA AGREEMENT DOES NOT ALLOW YOU TO BILL THE PATIENT FOR THE DIFFERENCE. IF YOU ARE IN INDIANA, CALIFORNIA OR TENNESSEE, PLEASE CONTACT CIGNA CUSTOMER SERVICE AT 1.800.88CIGNA (882.4462) FOR INFORMATION ON YOUR DISCOUNT RATE.

VIEN ELIGIBILITY, BENEFITS, AND CLAIM DETAILS AND GET PRECERTIFICATION ANSWERSFAST AT THE CIGNA FOR HEALTH CARE PROFESSIONALS WEBSITE (WWW.CIGNAFORHCP.COM)

SYS-BS7

G2433B 7-19-2002 PROCLAIN Provider Checkless EOP Summary

Clinical AnalysisService Dates 05/01/2012 - 08/01/2012

Patient No & Name Age Sex Home Phone Work Phone Usual Provider Prim Care Phys

Billing Provider:

609765 70 years F 727-771-9024 727-455-0654 Ext CELL 1BowmanMed. Rec. No: Med. Rec. Loc: EMR

724.4Voucher: 7691091 06/06/2012 Primary Diag: Actual Provider: 06/06/2012 Proc: 93922 Physiologic extremity study Units: 1 Diag 1: 724.4 Neuritis, lumbosacral NOS

Med. Rec. No: Med. Rec. Loc: EMR ONLY (paper chart completed)07/11/2012 Primary Diag: 724.4 Actual Provider:

68318 68 years M 727-787-3108 727-510-0575

Voucher: 786290007/11/2012 Proc: 99214 Mod:25 Office/output visit, est, detailed Units: 1 Diag 1: 724.4 Neuritis, lumbosacral NOS07/11/2012 Proc: 93922 Physiologic extremity study Units: 1 Diag 1: 443.9 Disease, peripheral vascular NOS

658607 54 years F 727-678-9285Med. Rec. No: Med. Rec. Loc:

Voucher: 7922680 07/16/2012 Primary Diag: 723.4 Actual Provider: 07/16/2012 Proc: 99214 Mod:25 Office/output visit, est, detailed Units: 1 Diag 1: 723.4 Neuritis, brachial NOS

Diag 2: 724.4 Neuritis, lumbosacral NOSDiag 3: 443.9 Disease, peripheral vascular NOSDiag 4: 354.0 Syndrome, carpal tunnel

07/16/2012 Proc: 93922 Physiologic extremity study Units: 1 Diag 1: 354.0 Syndrome, carpal tunnel

110822 55 years M 813-541-7963 813-826-7470Med. Rec. No: Med. Rec. Loc:

Voucher: 7681100 07/17/2012 Primary Diag: 722.10 Actual Provider: 07/17/2012 Proc: 99214 Office/output visit, est, detailed Units: 1 Diag 1: 722.10 Dsplcmnt, lumbar disc w/o myelpy

Diag 2: 443.9 Disease, peripheral vascular NOSDiag 3: 401.9 Hypertension, essential NOS

Diag 2: 443.9 Disease, peripheral vascular NOSDiag 3: 401.9 Hypertension, essential NOS

Diag 1: 722.10 Dsplcmnt, lumbar disc w/o myelpy07/17/2012 Proc: 93922 Physiologic extremity study Units: 1

614693 46 years F 813-920-3949 813-340-0834Med. Rec. No: Med. Rec. Loc:

Voucher: 7943900 07/10/2012 Primary Diag: 724.4 Actual Provider: 07/10/2012 Proc: 99214 Office/output visit, est, detailed Units: 1 Diag 1: 724.4 Neuritis, lumbosacral NOS

Diag 2: 729.1 Myalgia/myositis NOSDiag 3: 401.9 Hypertension, essential NOSDiag 4: 443.9 Disease, peripheral vascular NOS

Diag 2: 443.9 Disease, peripheral vascular NOSDiag 1: 401.9 Hypertension, essential NOS07/10/2012 Proc: 93922 Physiologic extremity study Units: 1

90311 69 years F 727-518-8370 2Kiriazi

Voucher: 7793100 06/12/2012 Primary Diag: 723.1 Actual Provider: 06/12/2012 Proc: 99213 Mod:25 Office/output visit, est, exp prob Units: 1 Diag 1: 723.1 Cervicalgia

Diag 2: 724.8 Symptom, back NECDiag 3: 720.1 Enthesopathy, spinalDiag 4: 728.4 Laxity, ligamentDiag 1: 720.1 Enthesopathy, spinal06/12/2012 Proc: 20550 Inject sngl tndn sheath/lgmnt apon Units: 1Diag 1: 720.1 Enthesopathy, spinal06/12/2012 Proc: 03490 Unclassified Drug Units: 1Diag 1: 720.1 Enthesopathy, spinal06/12/2012 Proc: 93922 Physiologic extremity study Units: 1Diag 1: 720.1 Enthesopathy, spinal06/12/2012 Proc: 95922 Autonomic nerv sys test, vasomotor Units: 1

Med. Rec. No: Med. Rec. Loc: EMR ONLY (paper chart completed)

604055 64 years M 813-926-1503 813-926-1503

Voucher: 7665480 06/20/2012 Primary Diag: 724.4 Actual Provider: 06/20/2012 Proc: 99213 Office/output visit, est, exp prob Units: 1 Diag 1: 724.4 Neuritis, lumbosacral NOS

06/20/2012 Proc: 93922 Physiologic extremity study Units: 1 Diag 1: 414.01 Athrsclr, coronary, native artery

Diag 2: 847.0 Sprain/strain, neckDiag 3: 304.00 Dependence, opiod, unspecified

Med. Rec. No: Med. Rec. Loc: EMR