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 WAregiiiiNOSIN .R. 02/26/2019 0000008048 1 Br trallipaMOVONO attogiagt 08/10/2016 I cg 2ffilf a it, 875.00 Paid by Paid By Charges Insurance Patient Adj. Balance 01/11/2019 99213 Est Pt Visit Expanded 93.41 93.41 01/11/2019 17000 Dest Ben/Premalig 1st 84.24 84.24 01/11/2019 17003 Dest Ben/Premal 2-14 22.23 22.23 kivt i t/9 Oil - . ti •iz Cu 6s4A 0 . e`)C. j 446 ry• dA 6 - . !fey:onto sclikelit 74.1.,Rurarm bi-:jai/001e At.7.,Eirrioa ViiiiSfitia reviewers ilislirs*itiliteAtt,tpi mat tatyr $0.00 $199.88 $0.00 $0.00 $0.00 Notes: CUT ON DOTTED LINE AND SEND WITH PAYMENT FOR BILLING INQUIRIES CONTAC EPSTEIN, JEFFREY ACCOUNT NO. 0000008048 Statement Date: 02/26/2019 Please remit payment of $199.88 payable to: MITCHELL A KLINE, MD PC EFTA00292227