Mediated Settlement Agreement Page 3
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3The following medical expenses shall be paid by Defendant(s) pursuant to the I.C. Fee Schedule under this settlement
agreement:
Provider
Charge
Amount Paid
Paid By
Balance Due
The following medical expenses are disputed by Defendant(s) and shall not to be paid by Defendant(s) under this
settlement agreement:
Provider
Charge
Amount Paid
Paid By
Balance Due
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