Fresenius Medical Care, NA PI). 00X 1370071131 PHILADELPHIA. PA 191911131 PI Vume: Snveriegn Valentine Allendmg Physician Shahld Chaudhaly smunm Nun-hm - anmpal 585 6 Account Number: Provider 83537FMC MISSOULA Dill: 06/19/2019 meder Tax ID 4: 31th um: Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 Rev Cd Den 2 Amounqs) 01/11/2019 636 J1644 HEPARIN-PORK 1000U 1ML 1 330.57 01/11/2019 636 J1644 HEPARIN-PORK 1000U 1ML 1 220.30 01/11/2019 304 00051 ELECTROLYTE PANEL 1 155160 01/11/2019 636 J1644 HEPARIN-PORK 1000U 1ML 1 220.30 01/11/2019 304 07340 HEPATITIS 0 SURFACE ANTIGEN 1 321.44 01/11/2019 304 06706 HEP 0 SURFACE AB (ANTI-HES) 1 334.77 01/11/2019 636 J1644 HEPARIN-PORK 1000U 1ML 1 330.57 01/11/2019 021 90999 HEMODIALYSIS TREATMENT 1 6,291.00 01/11/2019 304 04520 BUN, 00E (BLOOD UREA NITROGEN) 1 122.70 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES - INJ 1 106.21 nun/2019 304 06003 Hep vuus nn If1x cannm 1 255.13 01/11/2019 304 04520 BUN, POST, SERUM 1 122170 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES - INJ 1 106.21 01/11/2019 304 05025 COMPLETE BLOOD COUNT AND DIFFERENTIAL 1 566.70 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES - INJ 1 106.21 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES - INJ 1 106.21 01/11/2019 304 06704 HEPATITIS 0 CORE ANTIBODY 1 400.60 01/11/2019 304 02720 EERRITIN 1 424117 01/11/2019 304 02607 VITAMIN E12 1 469123 FMS 31'111'n office P.D. BOX 1 700-1131 PHILADELPHIA PA 191911131 Plan Name Palm bwnher 1 ALLEGIANCE BEN -- Somuegn Valanlmc PLAN MCA mus ADDRESS SERVICE REQUESTED SDVERIEGN VALENTINE Guanmmr Smemgn Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV Allendmg Physician Shahld Chaudhary smumm Numb: . Pnnupal Diagnosls :35 Number: Provider 0153 FMC MISSOULA 06/17/1019 meder Tax -- Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 01/11/2019 104 02745 EOLATE, SERUM 1 457170 01/11/2019 104 02040 ALBUMIN (ECG) 1 154111 01/11/2019 104 02110 CALCIUM 1 150141 01/11/2019 104 02100 ALUMINUM 1 791140 01/11/2019 104 02555 CREATININE, BLOOD 1 159120 01/11/2019 104 02110 CALCIUM 1 150141 01/11/2019 104 04100 PHOSPHORUS 1 147100 01/11/2019 104 04075 ALKALINE PHOSPHATASE 1 151110 01/11/2019 104 04155 TOTAL PROTEIN 1 114120 01/11/2019 104 04100 PHOSPHORUS 1 147100 01/11/2019 104 01550 UNBDUND IRON BINDING CAPACITY 1 272.12 01/11/2019 104 01540 IRON, SERUM 1 201151 01/11/2019 104 01970 EARATHORMDNE (17TH) 1 1,205129 01/11/2019 104 01715 MAGNESIUM 1 200150 01/14/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/14/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/14/2019 615 01644 HEYARIN-PDRK 1000U 1ML 1 220.10 01/14/2019 615 90712 PNEUMO VAC 21-VALEN 0.5 ML 1 251.99 01/14/2019 771 80009 PROF 1 171112 01/14/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/14/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/14/2019 615 01644 HEYARIN-PDRK 1000U 1ML 1 110.57 01/14/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/14/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/14/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/14/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/14/2019 615 01644 HEYARIN-PDRK 1000U 1ML 1 220.10 01/14/2019 615 01644 HEYARIN-PDRK 1000U 1ML 1 110.57 01/14/2019 615 01756 VENDFER 1 MG 1 2,501100 01/15/2019 615 01756 VENDFER 1 MG 1 2,501100 01/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/15/2019 615 01644 HEYARIN-PDRK 1000U 1ML 1 110.57 01/15/2019 615 01644 HEYARIN-PDRK 1000U 1ML 1 110.57 01/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 mus/2019 615 00037 Mxxcera mu vmox IVY 1 11,913.00 01/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/15/2019 615 01644 HEYARIN-PDRK 1000U 1ML 1 220.10 01/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 01/15/2019 615 90740 ENGERIX-E 40 MCG 1 2,511191 01/15/2019 771 80010 PROF 1 171.12 Page 2 or 15 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . - Pnnupal Diagnosls :35 Number: Provider 0153 FMC MISSOULA 06/17/1019 meder Tax Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 01/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/15/2019 021 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 01/15/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/15/2019 104 05010 HEMDGLOBIN 1 71157 01/15/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/10/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 110.57 01/10/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/10/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/10/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/10/2019 021 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/10/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 110.57 01/10/2019 615 01755 VENDFER 1 MG 1 2,501100 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 615 01755 VENDFER 1 MG 1 2,501100 01/21/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 110.57 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 021 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 01/21/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/21/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/21/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 110.57 01/21/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 110.57 01/21/2019 021 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 01/21/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/21/2019 615 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 615 NEW Mxxcera mu vmox IVP 1 11,913.00 01/21/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/21/2019 104 05010 HEMDGLOBIN 1 71157 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/21/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 Page a or 15 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . - Pnnupal Diagnosls :35 Number: Provider 0353 FMC MISSOULA 06/27/2019 Provider Tax ID '1 Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 01/23/2019 635 01755 VENDFER 1 MG 1 2,503.00 01/23/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/23/2019 304 04520 BUN, POST, SERUM 1 122170 01/23/2019 304 04520 BUN, PRE (BLOOD UREA NITROGEN) 1 122.70 01/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/25/2019 635 01755 VENDFER 1 MG 1 2,503.00 01/25/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 01/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/25/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/25/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 01/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/25/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 01/25/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/25/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/20/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/20/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/20/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 01/20/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/20/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 01/20/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/20/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/20/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/20/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/20/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 01/20/2019 635 01755 VENDFER 1 MG 1 2,503.00 01/20/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/30/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/30/2019 635 01755 VENDFER 1 MG 1 2,503.00 01/30/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/30/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 mun/2019 635 00037 Mxxcera znu vmox IVP 1 27,945.00 01/30/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/30/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/30/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/30/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 01/30/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/30/2019 304 05010 HEMDGLOBIN 1 73157 01/30/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/30/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 Page 4 or 15 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . Pnnupal Diagnosls :35 Number: Provider 8353 FMC MISSOULA 06/17/1019 Provider Tax ID 41 Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 01/30/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.18 02/01/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 02/01/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.18 02/01/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.18 02/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/01/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 02/01/2019 821 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 02/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/01/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 02/01/2019 635 01755 VENDFER 1 MG 1 1,251150 02/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/04/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 02/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/04/2019 821 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 02/04/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 02/04/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.18 02/04/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.18 02/04/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 02/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 352.61 02/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 02/05/2019 821 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 02/05/2019 104 05018 HEMDGLOBIN 1 73157 02/05/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 02/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.18 02/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.18 02/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/00/2019 635 01755 VENDFER 1 MG 1 1,251150 02/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 02/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 02/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 Page 5 or 15 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . - Pnnupal Diagnosls :35 Number: Provider 8353 FMC MISSOULA 06/27/2019 Provider Tax ID '1 Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 02/08/2019 821 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 02/08/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 02/08/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/08/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/08/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 330.57 02/11/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 330.57 02/11/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/11/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/11/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 02/11/2019 821 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 02/11/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/11/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/11/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/11/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 330.57 02/11/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/11/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/11/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/11/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 uz/u/znw 635 NEW Mxxcera znu vmox IVY 1 27,945.00 02/11/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/11/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 330.57 02/11/2019 104 85018 HEMDGLOBIN 1 73157 02/11/2019 821 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 02/11/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 02/11/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/11/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 330.57 02/11/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/15/2019 635 01755 VENDFER 1 MG 1 1,251150 02/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/15/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 02/15/2019 821 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 02/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/15/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 330.57 02/15/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/15/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/15/2019 270 A4657 ADMINISTRATION SUYYLIES -- INO 1 105.21 02/15/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 330.57 02/25/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 220.18 02/25/2019 635 01644 HEYARIN-PDRK 1000U 1ML 1 297.51 Page a or 15 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . Pnnupal Diagnosls :35 Number: Provider 8353 FMC MISSOULA 06/17/1019 meder Tax -- Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 02/25/2019 635 071644 HEPARIN-PDRK J000U JML 1 220.10 02/25/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 171.79 02/25/2019 021 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 02/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 02/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 02/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 02/25/2019 635 071644 HEPARIN-PDRK J000U JML 1 330.57 02/25/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 02/27/2019 104 04520 BUN, POST, SERUM 1 122170 02/27/2019 104 04520 BUN, PRE (BLOOD UREA NITROGEN) 122.70 02/27/2019 635 071644 HEPARIN-PDRK J000U JML 1 220.10 02/27/2019 635 071755 VENDFER 1 MG 1 2,503100 02/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 02/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 02/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 02/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 02/27/2019 635 071644 HEPARIN-PDRK J000U JML 1 297.51 02/27/2019 104 05010 HEMDGLOBIN 1 73157 02/27/2019 104 04132 POTASSIUM, SERUM 1 141104 02/27/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 171.79 02/27/2019 021 90599 HEMDDIALYSIS TREATMENT 6,291.00 02/27/2019 635 071644 HEPARIN-PDRK J000U JML 330.57 02/27/2019 635 071644 HEPARIN-PDRK J000U JML 220.10 02/27/2019 104 04132 POTASSIUM, SERUM 141104 02/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 105.21 01/01/2019 635 071644 HEPARIN-PDRK J000U JML 1 220.10 01/01/2019 635 071644 HEPARIN-PDRK J000U JML 1 220.10 01/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/01/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 171.79 01/01/2019 021 90599 HEMDDIALYSIS TREATMENT 1 6,291.00 01/01/2019 635 071644 HEPARIN-PDRK J000U JML 1 297.51 01/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/01/2019 635 071755 VENDFER 1 MG 1 2,503100 01/01/2019 635 071644 HEPARIN-PDRK J000U JML 1 330.57 01/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/04/2019 635 071644 HEPARIN-PDRK J000U JML 1 330.57 01/04/2019 635 071755 VENDFER 1 MG 1 2,503100 Page 7 or 15 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . Pnnupal Diagnosls :35 Number: Provider 0353 FMC MISSOULA 06/17/1019 meder Tax -- Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 01/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/04/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/04/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/04/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/04/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 297.51 01/04/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/04/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 297.51 01/05/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/05/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/05/2019 104 05010 HEMDGLOBIN 1 73157 01/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/05/2019 635 01755 VENDFER 1 MG 1 2,503100 01/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/00/2019 635 01755 VENDFER 1 MG 1 2,503100 01/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/00/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/00/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 297.51 01/11/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/11/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 305.67 01/11/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/11/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/11/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 Page a or 15 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . - Pnnupal Diagnosls :35 Number: Provider 0353 FMC MISSOULA 06/17/1019 meder Tax -- Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 01/11/2019 635 01755 VENDFER 1 MG 1 2,503100 01/11/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/11/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/13/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/13/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/13/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/13/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/13/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/13/2019 635 01755 VENDFER 1 MG 1 2,503100 01/13/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 297.51 01/13/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 01/13/2019 104 05010 HEMDGLOBIN 1 73157 01/13/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/13/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/13/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/13/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/15/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 297.51 01/15/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/15/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/15/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 01/15/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/15/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 330.57 01/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/15/2019 635 01755 VENDFER 1 MG 1 2,503100 01/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/10/2019 635 01755 VENDFER 1 MG 1 2,503100 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/10/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 305.67 01/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INJ 1 105.21 01/10/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 01/10/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/10/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/10/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 220.10 01/10/2019 635 071644 HEPARIN-PDRK 1000U 1ML 1 330.57 Page 9 or 15 Allendmg Phys1c1an anupal 0141;111:515 meder meder Tax ID 11 Fresenius Medical Care, NA PI). BOX 1370071131 PHILADELPHIA. PA 191911131 51141114 5 Chaudhary 185 6 8353 FMC MISSOULA Detail for: OP Serial I emo 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/24/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/22/2414 41/21/2414 41/21/2414 41/21/2414 144 144 144 144 144 144 144 144 144 515 144 144 144 515 144 144 2711 2711 144 144 515 515 421 2711 271 771 2711 515 2711 2711 2711 2711 515 515 421 271 515 515 515 515 515 41544 41554 44144 47144 41574 44155 44144 42114 42555 44447 44475 42444 42114 44744 44524 44524 A4557 A4557 44451 45425 41544 41544 44544 A4557 A5215 44414 A4557 41755 A4557 A4557 A4557 A4557 41544 41544 44544 A5215 41544 41544 41544 41544 41544 SnveriegnV mum Staten-141:thme . Number: 06/27/2019 01/11/2019 -- 04/27/2019 IRON, SERUM 1 241.51 UNBDUND IRON BINDING CAPACITY 1 272.12 PHOSPHORUS 1 147.44 HEYATITIS 11 SUREACE ANTIGEN 1 121.44 PARATHORMDNE 14T41 1 1,245.25 TOTAL PROTEIN 1 114.24 PHOSPHORUS 1 147.44 CALCIUM 1 154.41 CREATININE, BLOOD 1 154.24 Mxxcera 1511 445 1 211,554.54 ALRALINE PHOSPHATRSE 1 151.14 ALBUMIN 14Cs1 1 154.11 CALCIUM 1 154.41 ENGERIX-E 44 MCG 1 2,511.51 DUN, PRE 1DLOO4 UREA NITROGEN) 1 122.74 DUN, POST, SERUM 1 122.74 ADMINISTRATION SURRLIEs -- IN4 1 145.21 ADMINISTRATION SURRLIEs -- IN4 1 145.21 ELECTROLYTE RANEL 1 155.54 COMPLETE DLDOD COUNT AND 1 555.74 HEYARIN-PDRK 141111U 1ML 1 2211.14 HEYARIN-PDRK 141111U 1ML 1 2211.14 HEMDDIALYSIS TREATMENT 1 5,241.44 ADMINISTRATION SURRLIEs -- IN4 1 145.21 CATH CARE--INCL DRESSING CHANCE 1 171.74 PROF 1 171.12 ADMINISTRATION SURRLIEs -- IN4 1 145.21 VENOEER 1 MG 1 1,251.54 ADMINISTRATION SURRLIEs -- IN4 1 145.21 ADMINISTRATION SURRLIEs -- IN4 1 145.21 ADMINISTRATION SURRLIEs -- IN4 1 145.21 ADMINISTRATION SURRLIEs -- IN4 1 145.21 HEYARIN-PDRK 141111U 1ML 1 2211.14 HEYARIN-PDRK 141111U 1ML 1 2211.14 HEMDDIALYSIS TREATMENT 1 5,241.44 CATH CARE--INCL DRESSING CHANCE 1 171.74 HEYARIN-PDRK 141111U 1ML 1 1111.57 HEYARIN-PDRK 141111U 1ML 1 275.44 HEYARIN-PDRK 141111U 1ML 1 2211.14 HEYARIN-PDRK 1444U 1ML 1 241.51 HEYARIN-PDRK 141111U 1ML 1 2211.14 Pagemaus Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . Pnnupal Diagnosls :35 Number: Provider 8353 FMC MISSOULA 06/17/1019 meder Tax -- Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 01/27/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 330.57 01/27/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/27/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/27/2019 104 05010 HEMDGLOBIN 1 73157 01/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/27/2019 635 01755 VENDFER 1 MG 1 2,503100 01/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/27/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/29/2019 104 04520 BUN, PRE (BLOOD UREA NITROGEN) 1 122.70 01/29/2019 104 04520 BUN, POST, SERUM 1 122170 01/29/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/29/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/29/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 220.10 01/29/2019 635 01755 VENDFER 1 MG 1 2,503100 01/29/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/29/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 330.57 01/29/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 01/29/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 01/29/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 297.51 01/29/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/29/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 01/29/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 220.10 04/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/01/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/01/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 04/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/01/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 220.10 04/01/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 297.51 04/01/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 330.57 04/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/01/2019 635 01755 VENDFER 1 MG 1 2,503100 04/01/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 220.10 04/01/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 220.10 04/01/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 330.57 04/01/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/01/2019 635 01644 HEPARIN-PDRK 10000 1ML 1 330.57 04/03/2019 635 NEW Mxxcera mu vmox IVP 2 27,945.00 Page 11 ans Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . - Pnnupal Diagnosls :35 Number: Provider 8353 FMC 06/27/2019 Provider a -- Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 04/03/2019 635 01755 VENDFER 1 MG 1 2,503.00 04/03/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 04/03/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/03/2019 304 05010 HEMDGLOBIN 1 73157 04/03/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 04/03/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/03/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/03/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/03/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/05/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/05/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 04/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/05/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 205.49 04/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 04/05/2019 635 01755 VENDFER 1 MG 1 2,503.00 04/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 04/05/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 04/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/00/2019 635 01755 VENDFER 1 MG 1 2,503.00 04/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 04/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 04/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/00/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 04/00/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/00/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 04/00/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 04/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/10/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 04/10/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.30 04/10/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 173.79 04/10/2019 304 05010 HEMDGLOBIN 1 73157 04/10/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 Page 120115 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . Pnnupal Diagnosls :35 Number: Provider 8353 FMC MISSOULA 06/17/1019 meder Tax Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 04/10/2019 635 01755 VENDFER 1 MG 1 2,503100 04/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/10/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/10/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 297.51 04/10/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/12/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/12/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/12/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/12/2019 635 01755 VENDFER 1 MG 1 2,503100 04/12/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/12/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/12/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/12/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 04/12/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/12/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/12/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 04/12/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 297.51 04/15/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 04/15/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 297.51 04/15/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/15/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/15/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 04/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/15/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/15/2019 635 01755 VENDFER 1 MG 1 2,503100 04/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/15/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/17/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/17/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/17/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/17/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/17/2019 104 01550 UNBDUND IRON BINDING CAPACITY 1 272.12 04/17/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 04/17/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 205.49 04/17/2019 104 04520 BUN, PRE (BLOOD UREA NITROGEN) 1 122.70 04/17/2019 104 00051 ELECTROLYTE PANEL 1 155160 04/17/2019 104 05025 COMPLETE BLOOD COUNT AND DIFFERENTIAL 1 555.70 04/17/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/17/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 Fresenius Medical Care, NA no. BOX 137004131 PHILADELPHIA. PA 19mm: rum-u: SnveriegnV mum Allendmg Physician Shahld Chaudhary smumm Numb: . Pnnupal Diagnosls :35 Number: Provider 0353 FMC MISSOULA 06/17/1019 meder Tax -- Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 04/17/2019 104 04520 BUN, POST, SERUM 1 122170 04/17/2019 104 01970 PARATHORMDNE (PTHI 1 1,205129 04/17/2019 104 02555 CREATININE, BLOOD 1 159120 04/17/2019 104 02110 CALCIUM 1 150141 04/17/2019 104 02110 CALCIUM 1 150141 04/17/2019 104 07140 HEPATITIS 0 SURFACE ANTIGEN 1 321.44 04/17/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/17/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 04/17/2019 104 04155 TOTAL PROTEIN 1 114120 04/17/2019 104 04100 PHOSPHORUS 1 147100 04/17/2019 104 04100 PHOSPHORUS 1 147100 04/17/2019 104 01735 MAGNESIUM 1 200150 04/17/2019 104 04075 ALKALINE PHOSPHATASE 1 151110 04/17/2019 104 02040 ALBUMIN (ECG) 1 154111 04/17/2019 104 01540 IRON, SERUM 1 201151 04/17/2019 104 02720 EERRITIN 1 424117 04/19/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 297.51 04/19/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/19/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 330.57 04/19/2019 271 A6215 CATH CARE--INCL DRESSING CHANGE 1 171.79 04/19/2019 021 90999 HEMDDIALYSIS TREATMENT 1 6,291.00 04/19/2019 635 01644 HEPARIN-PDRK 1000U 1ML 1 220.10 04/19/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/19/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/19/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 04/19/2019 270 A4657 ADMINISTRATION SUPPLIES -- INO 1 105.21 Total Charges $540,511.90 03/20/2019 ALLEGIANCE BEN PLAN ~502124 03/20/2019 ALLEGIANCE BEN PLAN -1,956130 03/20/2019 ALLEGIANCE BEN PLAN -1,411162 03/20/2019 ALLEGIANCE BEN PLAN ~470154 03/20/2019 ALLEGIANCE BEN PLAN ~701177 04/10/2019 ALLEGIANCE BEN PLAN ~941100 04/10/2019 ALLEGIANCE BEN PLAN ~470154 04/10/2019 ALLEGIANCE BEN PLAN -1,411162 04/10/2019 ALLEGIANCE BEN PLAN -1,411162 05/17/2019 ALLEGIANCE BEN PLAN -1,706145 05/17/2019 ALLEGIANCE BEN PLAN ~941100 05/17/2019 ALLEGIANCE BEN PLAN -1,411162 Page Mans Fresenius Medical Care, NA PI). BOX 1370071131 PHILADELPHIA. PA 191911131 P1 Vume: Snveriegn Valentine Allendmg Physician Shahld Chaudhaly smunm Number: anmpal 585 6 Account Number: Provider 83537FMC Ml D111 . 06/27/2019 mederTax ID 4: 31th um: Detail for: OP Serial IC Hemo 01/11/2019 -- 04/27/2019 (Conlmued) 05/30/2019 ALLEGIANCE BEN PLAN 05/30/2019 ALLEGIANCE BEN PLAN Total Payment: 5-1534: . 7: Bulnnu $524,600.17 1F Ev V1SA MASYERCARD mscovER an AMERICAN EXPRESS FILL ow BELOW Wm :9 gm 71 a 1 FRESEN1US MED1CAL CARE FRESENIUS M1SSOULA KIDNEY CARE PO Box 535300 OH 45263-5800 mu: wow: Accuum No. Pay anline at: ipay.lmcna.cnm 06/19/2019 $524600 17 - DUE 4 SHOW AMOUNY For all hIllmg quesuons, 07/09/2019 mu HERE 5 Please call: 355--352-5355 mm mm mm mum SOVER1EGN VALENT1NE FRESEN1US MEDICAL CARE M1SSOULA PO BOX 635800 CINCINNAT1 OH 452 800 1' ,4111' Jun, 1 11,, 1 '11; 1 1'11" Date; nI Marmara other Tam Gamma: Lasl Guarantor Amnum Du: Massage SerIce Charges Faymenl Faymenl Adjustments Faymenl Faymenl Dale mammal (see back) 01111119011121? FMC M1 $15429 23 $0 00 $502 24 $0 00 $0 00 $14926 99 01031190109719 FMC M1 $40103 47 $0 00 $1955 30 $0 00 $0 00 $4722717 01720119002671? FMC M1 $46094 45 $0 00 $141152 $0 00 $0 00 $44682 83 01/ 9011' HE FMC M1 $49221 $49221 15 FMC M1 $9349 24 $0 00 $470 54 $0 00 $0 00 $8878 70 FMC M1 $25428 01 $0 00 $783 77 $0 00 $0 00 $24644 24 FMC M1 $53351 $53351 97 1--1 FMC M1 $1913146 $0 00 $94108 $000 $0 00 $18190 38 FMC M1 $10567 68 $0 00 $470 54 $0 00 $0 00 $1009714 FMC M1 $31776 71 $0 00 $141152 $0 00 $0 00 $30365 09 0311 9430116719 FMC M1 $31864 87 $0 00 $141152 $0 00 $0 00 $30453 25 0311 9430123719 FMC M1 $55073 45 $0 00 $1706 45 $0 00 $0 00 $53366 99 03/2 FMC M1 $21454 59 $0 00 $941 08 $0 00 $0 00 $20513 51 0410 904106719 FMC M1 $59744 75 $0 00 $141152 $0 00 $0 00 $5833313 0410 904113719 FMC M1 $31809 77 $0 00 $141152 $0 00 $0 00 $3039815 04114119041200? FMC M1 $31361 10 $0 00 $141152 $0 00 $0 00 $29949 48 Current 31-60 Days 61-90 Days 91420 Days Over 120 Days, AMOUNT DUE 552460017 $50347 53 $132213 53 $191678 98 $140359 93 $0 00 Tma1paymenlsapp11ed 50 Do Vour acCoImI Is very ser1ous1y past due P1ease rem payment 1mmed1a1e1y tn avuld mnher Co11eClIorI 1. cm: 115300;. "50wa CINCWNAM on 4529050017 131 3554524355 My cum .1 1mm". com REVERSE SIDE FOR IMPORTANT BILLING INFORMATION