Statement of Account MITCHELL A KLINE, MD PC 700 PARK AVENUE NEW YORK, NY 10021 07/27/2016 0000008048 | 1 | Last Payment 04/07/2016 | 1525.00 JEFFREY EPSTEIN 9 EAST 71ST STREET NEW YORK, NY 10021 Paid by Paid By Date Procedure Description Charges Insurance _ Patient Adj. Balance 07/27/2016 | 99205 | New Pt High Complexity 07/27/2016 | 11100 | Biopsy/Skin, 1st 07/27/2016 | 11101 | Biopsy/Skin Each Additional i 0-30 Days | 31 - 60 Days | 61 - 90 Days |91 - 120 Days; > 120 Days Patient Current Past Due Past Due Past Due Past Due Balance Due TTTTTTTETT==S==°°°°°° Gist GN BOTTED LINE AN SEND with PAvineNT ~~” PORE” Cys SEEEREY Fx Notes: % ‘6 FOR BILLING INQUIRIES CONTACT [A ACCOUNT NO: 0000008048 Statement Date: 07/27/2016 Please remit payment of $875.00 payable to: MITCHELL A KLINE, MD PC EFTA00316268

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