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Amt. No. Exp. Date Security Code Amount Signature EPSTEIN. JEFFREY ACCOUNT NO. 0000008048 Statement Date: 01/28/2015 payable to: MITCHELL A KLINE, MD PC EFTA00311355 Statement of Account ERD PC JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Date Procedure Description Date I
0 Paid by Charges Insurance 01/22/2015 01/22/2015 01/22/2015 01/22/2015 99205 11100 17000 17003 New Pt High Complexity Biopsy/Skin, 1st Dest Ben/Premalig 1st Dest Ben/Premal 2-14 1 .AA g 1‘ S o y 500.00 250.00 175.00 50.00 Paid By Patient Adj. Balance 500.00 250.00 175.00 50.00 0 - 30 D
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Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY 10021 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 110%, :Wait 02/05/2015 I 0000008048 1 02/0
5 01222015 99205 11100 17000 17003 nit..-.. A n.tne N n. 729 PCS AVM 1611 new. in• 16321 IIIIIIIf New Pt High Complexity Biopsy/Skin, 1st Dest Ben/Premalig 1st Dest Ben/Premal 2-14 herthemt MESS:332443 Try ID: 51,302443 Rirf II: Won Phone Order turoutia pEk Entn NS& !trial Tote: $ 1.21N Ritt
2 mentions1 same-page
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Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY 10021 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Date Procedure Description ingatMli WAregii
Description Paid by Charges Insurance Paid By Patient Adj. Balance 01/11/2019 01/11/2019 99212 17000 Established Pt Visit Straightfwrd Dest Ben/Premalig 1st 250 25'.00 250.00 250.00 01/11/2019 17003 Dest Ben/Premal 2-14 50.00 150.00 A Gate- 1,,ni- efruct, ivtt 4 -c c) 0 el 0-- 04- tecil vt
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