Short Hills Assoc in Clinical 28 Mil/bum Avenue Suite 1 Springfield, NJ 070811089 (973)467-9333 Bill To: Bill For: Date Transaction CPT Code POS Diagnosis Units Charge Total Owed 11/17/2011 90806 11 309.28 1 $125.00 $125.00 1/17/2013 Payment, $200.00 ($25.00) 12/1/2011 Famity 90847 11 309.28 1 $125.00 $125.00 12/7/2011 Individual 90806 11 309.28 1 $125.00 $125.00 12/15/2011 Individual 90808 11 309.28 1 $125.00 1 812500 1/5/2012 1ndividua1 90806 11 309.28 1 $100.00 310000 1/7/2012 Group 90853 11 309.28 1 $40.00 54000 1/28/2012 Group 90853 11 309.28 1 $40.00 $40.00 2/1/2012 Individual! 90806 11 309.28 1 $100.00 $100.00 2/18/2012 Group 90853 11 309.28 1 $40.00 $40.00 2/29/2012 Individual 90806 11 309.28 1 $100.00 $100.00 3/10/2012 Group 90853 11 309.28 1 $40.00 $40.00 3/29/2012 90806 11 309.28 1 $100.00 $100.00 4/14/2012 Group 90853 11 3092831400 1 $40.00 $40.00 4/21/2012 Group 90853 11 3092031400 1 $40.00 $40.00 5/5/2012 Group 90853 11 3092831400 1 $40.00 $40.00 5/12/2012 Group 90853 11 3092801000 1 840.00 840.00 NancyB/anco Melendez, 1215182241 License Number: 4593 Tax Id: 222778288 NPI: 1215182241 Short Hills Assoc in Clinical 28 Mil/bum Avenue Suite 1 Springfield, NJ 070811089 (973)467-9333 Bill To: Bill For: Date Transaction CPT Code POS Diagnosis Units Charge Total Owed 5/19/2012 90853 11 309.28.314.00 1 $40.00 $40.00 1/9/2013 45 minutes 90834 11 3092831400 1 $100.00 $100.00 1/17/2013 45 minutes 90834 11 3092831400 1 $100.00 i $100.00 1/24/2013 45 minutes 90834 11 3092831400 1 $100.00 $100.00 2/6/2013 45 minutes 90834 11 309.28.314.00 1 $100.00 810000 2/15/2013 45 minutes 90834 11 3092831400 1 $100.00 $100.00 2/28/2013 45 minutes 90834 11 309.28.314.00 1 $100.00 $100.00 3/14/2013 Individual 90806 11 309.28.314.00 1 $100.00 $100.00 3/31/2013 45 minutes 90834 11 3092801400 1 $100.00 . $100.00 4/20/2013 45 minutes 90834 11 309.28.314.00 1 $100.00 $100.00 $2,160.00 $2,135.00 Piease Pay this Amount: 52.13500 NancyB/enco Melendez, 1215182241 License Number: 4593 Tax Id: 222778288 1215182241