For Plvmunl nnIy:

 

Box 4200
Ncusron' Texas 77210 <<258 l-
'l CHI St.Luke's
AII InquIrIu wan: Health
0 Box 20505
Houston, Texas 772250505
um: um mscu on: m:
DAVID 000 KVETDN 01/24/2017 02/02/2017 75 cl 75

 

0000A
HERLIHY, JAMES 
msuuncz 
1 MEDICARE A 
anon>> No NVOICE N0
1005103841308

 

conAMY
2 MCII - 

 

 

NEALTHCARE

Rev Code Dale QI Ameum

0636 2/707 HC53600020 PHENYLEPNRINE PER I ML 10

0636 2mm Hcfiawoozu PER I MG 1

0636 2/2/17 PER 1 MG 1 

0637 02007 Hcsseouozu IN SODIUM CHLORIDE 100 ML BAG 20 

0637 1/2007 INSULIN IN SODIUM CHLORIDE 100 ML BAG I 20 I

0637 2007 REGULAR HUMAN PER 5 I 2

0637 2/207 REGULAR HUMAN PER 5 UNITS I 60

0637 2/207 JNSULIN REGULAR HUMAN PER 5 UNITS I 60

0637 2/207 REGULAR HUMAN PER 5 UNITS I 2

0537 2/707 REGULAR HUMAN PER 5 UNITS 60 I

0740 020/17 Hc74000r00 NC EEG EXT 1 I

0500 02707 HC DAILY 1

0800 1/2007 I Hcaonunfluz DAILY 1 I

0500 01907 HCBOODOOM DAILY 1 1 I

11800 1/3007 HC DAILY 1 

0000 II3I07 Hc00000002 HC DAILY 1 I .

0500 2007 Henna/10001 HC DAILY 1 . .

00m 1/2507 IHC HEART TRANSPORTATION I I 

am: 02507 Hcatznoaoa HC HEART I i 7, 102.000

 

Total Charges: 1,060,12550

All Insurance Benefits
Io
CHI Luke's Health


5 
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MW 1/5/1017 7 1:25 PM

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