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HomeMy WebLinkAbout04-14-09WEST' VIRGINIA UNIVERSITY HOSPT_T_AT S Morgantown, West Virginia In the matter of the estate of C.l ~ ~S e ~jc.t.. ~ ~ deceased, The undersigned, being first duly sworn, says: that he is a creditor (that he is a duly Proof of Claim -Against Decedent's Estate ~~cc Pen ing b fore ~1~ ~~ Q ounty, West Virginia authorized agent of a creditor) of the estate of the above named decedent: that the character of his claim is /~... I~S~ ~ - that the amount thereof is $ ~ , Q `7~ • ~ ~ , w interest from the day of ~ 19' , 20 ,until paid. That a proper voucher relating to said claim is hereto attached; that the said claim is just and true and that the said creditor, or any N_ prior owner of the claim, if any there was, hath not received any of the mon~~ated f~be d~~5:ar Tip ~ ~ ~ any security or satisfaction for the same except that which is credited. ; -.b ~ t - _ - ~. . i i J /^ 1 ...., r~...~. Affiant y N "' Taken, sworn to and subscribed before me this the day of /~~ ~ , 20 . P. My commission expires ~ J ~ . ~ OfNCiel Ssel ~ ° NWery Public, State of WeelVkpnia - MelYSea SteweA * a 70 Oulet Dell lens Fairmont, VW p~gq '"iO'a My Commtaaion Expires February 13, 2019 PA-008 (R 8/02) WVU HOSPITALS PO BOX 1127 MORGANTOWN, WV 26057-1127 Ph: 304-598-4032 Guarantor Number 100128647 Account Number 227416 Detailed Bill For Patient Name: Account Class: Attending Physician: Charges Guarantor Name & Address BUTTORFF,LOUISE 219 HALDERMAN AVE BAD ADDRESS NEW CUMBERLAND, PA 17070 BUTTORFF,LOUISE S Admission Date: 07/22/2008 Inpatient Discharge Date: 08/21/2008 BROOKS, CLAUDETTE E Service Cost Rev. Proc. --- Description --------y--- Qt -=_______ Amount Date Ctr. Code Code 07/28/08 350 0022 300231 HCHG RUG 'S - RVX 14 0 00 08/03/08 350 0022 300189 HCHG RUG 'S - RVB 16 . 07/22/08 350 0120 100023 HCHG SNU ROOM 1 0.00 07/23/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/24/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/25/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/26/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/27/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/28/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/29/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/30/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/31/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/01/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/02/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/03/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/04/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/05/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/06/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/07/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/08/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/09/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/10/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/11/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/12/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/13/08 350 0120 100023 HCHG SNU ROOM 435.00 08/14/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/15/08 350 0120 100023 HCHG SNU ROOM 1 1 435.00 08/16/08 350 0120 100023 HCHG SNU ROOM 435.00 08/17/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/18/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/19/08 350 0120 100023 HCHG SNU ROOM 1 435.00 08/20/08 350 0120 100023 HCHG SNU ROOM 1 435.00 07/22/08 230 0250 110034 TOLTE RODI NE TAB 2MG 1 1 435.00 07/22/08 230 0250 110031 TUBER CULI N P PD INTE 1 8.17 07/23/08 230 0250 110034 ESOME PRAZ OLE (NEXIU 1 7.41 *MS 3.26 07/23/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 07/23/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/23/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 07/24/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 07/24/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/24/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 8.17 07/24/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/25/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 07/25/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 07/25/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 07/25/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/26/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 07/26/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 07/26/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/26/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 8.17 07/27/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/27/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 07/27/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 07/27/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/28/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 07/28/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 07/28/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/28/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 07/29/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 07/29/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 07/29/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/29/08 230 0250 110031 TUBERCULIN P PD INTE 1 8.17 07/29/08 230 0250 110034 TOLTERODINE TAB 2MG 1 7.41 07/30/08 230 0250 110034 ACETAMINOPHE N TAB 3 2 8.17 07/30/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 6.52 07/30/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 07/30/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/30/08 230 0250 110034 FLUOXETINE C AP 20MG 1 8.17 07/30/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 07/30/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 07/31/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 07/31/08 230 0250 110034 ACETAMI~'OPHE N TAB ~ 2 3.26 07/31/08 230 0250 110034 TOLTERODINE TAB 2MG/ 1 6.52 07/31/08 230 0250 110034 PREDNISONE T AB 2.5M 1 8 17 07/31/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 07/31/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/01/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 3.26 08/01/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/01/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 08/01/08 230 0250 110034 ACETAMINOPHE N TAB 3 2 8.17 08/01/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 6.52 08/01/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/01/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/01/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/02/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 08/02/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/02/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/02/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 08/02/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/02/08 230 0250 110034 TOLTERODINE TAB 2MG 3.26 *MS 1 8.17 08/03/08 230 0250 110034 TOLTERODINE TAB 2MG 1 08/03/08 230 0250 110034 PREDNISONE T AB 2 5M 8.17 08/03/08 230 0250 110034 . TOLTERODINE TAB 2MG 1 1 3.26 08/03/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 8.17 08/03/08 230 0250 110034 ASPIRIN E C TAB 32 1 3.26 08/03/08 230 0250 110034 . . FLUOXETINE C AP 20MG 1 3.26 08/04/08 230 0250 110034 TOLTERODINE TAB 2MG 1 1 3.26 08/04/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 8.17 08/04/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 1 3.26 08/04/08 230 0250 110034 PREDNISONE T AB 2 5M 3.26 08/04/08 230 0250 110034 . TOLTERODINE TAB 2MG 1 3.26 08/04/08 230 0250 110034 FLUOXETINE C AP 20MG 1 8.17 08/05/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 3.26 08/05/08 230 0250 110034 TOLTERODINE TAB 2MG 1 1 3.26 08/05/08 230 0250 110034 PREDNISONE T AB 2.5M 1 8.17 08/05/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 08/05/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/05/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/05/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/06/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 08/06/08 230 0250 110034 PREDNISONE T AB 2.5M 1 8.17 08/06/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/06/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/06/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/06/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 08/06/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/07/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/07/08 230 0250 110034 PREDNISONE T AB 2.5M 1 8.17 08/07/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/07/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 3.26 08/07/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 08/07/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/07/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/08/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 08/08/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/08/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/08/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 08/08/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/08/08 230 0250 110034 PREDNISONE T AB 2.5M 1 8.17 08/08/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/09/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/09/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 8.17 08/09/08 230 0250 110034 ASPIRIN E C TAB 32 1 3.26 08/09/08 230 0250 110034 . . PREDNISONE T AB 2 5M 1 3.26 08/09/08 230 0250 110034 . FLUOXETINE C AP 20MG 1 3.26 08/09/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/09/08 230 0250 110034 TOLTERODINE TAB 2MG 1 1 3.26 08/10/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/10/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/10/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 8.17 08/10/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/10/08 230 0250 110034 FLUOXETINE C AP 20MG 3.26 08/10/08 230 0250 110034 TOLTERODINE TAB 2MG 1 1 3.26 08/10/08 230 0250 110034 ERGOCALCIFER OL CAP 1 8.17 08/11/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 3.26 *MS 1 3.26 08/11/08 230 0250 110034 TOLTERODINE TAB 2MG 1 08/11/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 8.17 08/11/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/11/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/11/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/11/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/12/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/12/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/12/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 8.17 08/12/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/12/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/12/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/12/08 230 0250 110034 ACETAMINOPHE N TAB 3 2 3.26 08/12/08 230 0250 110034 TOLTERODINE TAB 2MG 1 6.52 08/13/08 230 0250 110034 BAG BALM 8.17 08/13/08 230 0250 110034 , ESOMEPRAZOLE (NEXIU 1 1 17.82 08/13/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/13/08 230 0250 110034 ACETAMINOPHE N TAB 3 2 8.17 08/13/08 230 0250 110034 PREDNISONE T AB 2 5M 1 6.52 08/13/08 230 0250 110034 . ASPIRIN E.C. TAB 32 1 3.26 08/13/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/13/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/14/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 3.26 08/14/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/14/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 08/14/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 8.17 08/14/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/14/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/14/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/14/08 230 0250 110034 ERGOCALCIFER OL CAP 1 8.17 08/15/08 230 0250 110034 ACETAMINOPHE N TAB 3 2 3.26 08/15/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 6.52 08/15/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 08/15/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/15/08 230 0250 110034 FLUOXETINE C AP 20MG 1 8.17 08/15/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/15/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/15/08 230 0250 110034 ERGOCALCIFER OL CAP 1 8.17 08/16/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/16/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/16/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/16/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 3.26 08/16/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/16/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/16/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/17/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/17/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/17/08 230 0250 110034 ASPIRIN E.C. TAB 32 1 8.17 08/17/08 230 0250 110034 PREDNISONE T AB 2.5M 1 3.26 08/17/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/17/08 230 0250 110034 ERGOCALCIFER OL CAP 1 3.26 08/17/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/18/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 08/18/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/18/08 230 0250 110034 ASPIRIN E.C. TAB 32 3.26 *MS 1 3.26 0'8/18/08 08/18/08 230 230 0250 110034 PREDNISONE T AB 2.5M 1 3 26 08/18/08 2 0250 110034 FLUOXETINE C AP 20MG 1 . 3 26 08/18/08 30 2 0250 110034 ERGOCALCIFER OL CAP 1 . 3 26 08/19/08 30 230 0250 110034 TOLTERODINE TAB 2MG 1 . 8 17 08/19/08 230 0250 110034 ESOMEPRAZOLE N U 1 . 3 26 08/19/08 230 0250 0250 110034 TOLTERODINE TAB 2MG 1 . 8 17 08/19/08 230 0250 110034 110034 ASPIRIN E.C. TAB 32 1 . 3.26 08/19/08 230 0250 110034 FLUOXETINE C AP 20MG PREDNISONE T AB 1 3.26 08/19/08 230 0250 110034 2.5M ERGOCALCIFER OL CAP 1 3.26 08/19/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/20/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/20/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/20/08 230 0250 110034 BAG BALM 1 8.17 08/20/08 230 0250 110034 , PREDNISONE T AB 2 5M 1 17.82 08/20/08 230 0250 110034 . ASPIRIN E C TAB 32 1 3.26 08/20/08 230 0250 110034 . . ERGOCALCIFER OL CAP 1 3.26 08/20/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/20/08 230 0250 110034 TOLTERODINE TAB 2MG 1 3.26 08/21/08 230 0250 110034 TOLTERODINE TAB 2MG 1 8.17 08/21/08 230 0250 110034 ESOMEPRAZOLE (NEXIU 1 8.17 08/21/08 230 0250 110034 PREDNISONE T AB 2 5M 1 3.26 08/21/08 230 0250 110034 . ASPIRIN E.C TAB 32 1 3.26 08/21/08 230 0250 110034 . ERGOCALCIFER OL CAP 1 3.26 08/21/08 230 0250 110034 FLUOXETINE C AP 20MG 1 3.26 08/21/08 230 0250 110031 HEPARIN (500 0 UNITS 1 3.26 07/23/08 619 0270 500043 HCHG SLEEVE, SEQUENTIAL CO 1 08/12/08 619 0270 500029 HCHG TRAY, URETHRAL OATH 1 459.00 08/15/08 08/15/08 101 101 0300 600054 , . HCHG ASSAY OF UREA NITROGE 1 36.50 19 00 08/15/08 101 0300 03 600084 HCHG ELECTROLYTE PANEL . 28 50 08/12/08 155 00 0351 600014 HCHG ASSAY OF CREATININE i . 07/24/08 210 0420 800360 300457 HCHG CT HEAD/BRAIN W/O DYE 1 751.00 07/25/08 210 0420 300457 HCHG GAIT TRAINING HCHG GAIT TRAINING 1 64.00 07/28/08 210 0420 300457 HCHG GAIT TRAINING 1 64.00 07/29/08 210 0420 300457 HCHG GAIT TRAINING 1 64.00 07/30/08 210 0420 300457 HCHG GAIT TRAINING 1 64.00 07/31/08 210 0420 300457 HCHG GAIT TRAINING 1 64.00 08/01/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/04/08 210 0420 3Q0457 HCHG GAIT TRAINING 2 128.00 08/05/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/06/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/07/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/08/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/11/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/12/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/13/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/14/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/15/08 210 0420 300457 HCHG GAIT TRAINING 1 64.00 08/18/08 210 0420 300457 HCHG GAIT TRAINING 1 64.00 08/19/08 210 0420 300457 HCHG GAIT TRAINING 2 128.00 08/20/08 210 0420 300457 HCHG GAIT TRAINING 1 64.00 07/24/08 07/25/08 210 210 0421 300567 HCHG PHYSICAL THERAPY TREA 2 127 00 07/28/08 210 0421 0421 300567 HCHG PHYSICAL THERAPY TREA 2 . 127.00 *MS 300567 HCHG PHYSICAL THERAPY TREA 2 127.00 07/29/08 0'7/30/08 210 210 0421 300567 HCHG PHYSICAL THERAPY TREA 2 127 00 07/31/08 210 0421 0421 300567 3 HCHG PHYSICAL THERAPY TREA 1 . 08/01/08 210 0421 00567 300567 HCHG PHYSICAL THERAPY TREA 2 127.00 08/04/08 210 0421 300567 HCHG PHYSICAL THERAPY TREA HCHG PHYSICAL 2 127.00 08/05/08 210 0421 300567 THERAPY TREA HCHG PHYSICAL THERAPY TREA 2 127.00 08/06/08 08/07/08 210 210 0421 300567 HCHG PHYSICAL THERAPY TREA 2 2 127.00 127 00 08/08/08 210 0421 0421 300567 HCHG PHYSICAL THERAPY TREA 1 . 08/11/08 210 0421 300567 300567 HCHG PHYSICAL THERAPY TREA 2 127.00 08/12/08 210 0421 300567 HCHG PHYSICAL THERAPY TREA HCHG PHYSICAL THERAPY 2 127.00 08/13/08 210 0421 300567 TREA HCHG PHYSICAL THERAPY TREA 1 2 63.50 08/14/08 08/15/08 210 210 0421 300567 HCHG PHYSICAL THERAPY TREA 1 127.00 63 50 08/18/08 210 0421 0421 300567 HCHG PHYSICAL THERAPY TREA 1 . 63.50 08/20/08 210 0421 300567 300567 HCHG PHYSICAL THERAPY TREA 2 127.00 07/23/08 210 0424 300576 HCHG PHYSICAL THERAPY TREA HCHG PT EVAL 38 2 07/23/08 213 0431 300564 TO 52 MIN HCHG OT-TREATMENT 1 181.50 07/24/08 213 0431 300564 HCHG OT-TREATMENT 2 147.00 07/25/08 213 0431 300564 HCHG OT-TREATMENT 4 294.00 07/28/08 213 0431 300564 HCHG OT-TREATMENT 3 220.50 07/30/08 213 0431 300564 HCHG OT-TREATMENT 3 220.50 07/31/08 213 0431 300564 HCHG OT-TREATMENT 3 220.50 08/01/08 213 0431 300564 HCHG OT-TREATMENT 4 294.00 08/04/08 213 0431 300564 HCHG OT-TREATMENT 4 294.00 08/06/08 213 0431 300564 HCHG OT-TREATMENT 2 147.00 08/07/08 213 0431 300564 HCHG OT-TREATMENT 3 220.50 08/08/08 213 0431 300564 HCHG OT-TREATMENT 2 147.00 08/12/08 213 0431 300564 HCHG OT-TREATMENT 3 220.50 08/13/08 213 0431 300564 HCHG OT-TREATMENT 3 220.50 08/15/08 213 0431 300564 HCHG OT-TREATMENT 3 220.50 08/18/08 213 0431 300564 HCHG OT-TREATMENT 3 220.50 08/19/08 213 0431 300564 HCHG OT-TREATMENT 4 294.00 08/20/08 213 0431 300564 HCHG OT-TREATMENT 2 147.00 07/23/08 213 0434 300555 HCHG OT EVAL 23 TO 37 MIN i 220.50 07/24/08 214 0441 300618 HCHG SP/LG TX 38 TO 52 MIN 146.50 07/25/08 214 0441 300618 HCHG SP/LG TX 38 TO 52 MIN 1 137.50 07/28/08 214 0441 300622 HCHG SP/LG TX 8 TO 22 MIN 1 137.50 07/29/08 214 0441 300618 HCHG SP/LG TX 38 TO 52 MIN 1 07/30/08 214 0441 300617 HCHG SP/LG TX 23 TO 37MIN 1 137.50 07/31/08 214 0441 300618 HCHG SP/LG TX 38 TO 52 MIN 1 08/01/08 214 0441 300622 HCHG SP/LG TX 8 TO 22 MIN 1 137.50 08/04/08 214 0441 300619 HCHG SP/LG TX 53 TO 67 MIN 1 47.00 08/04/08 214 0441 360071 HCHG SW TX 23 TO 37 MIN 1 183.00 08/05/08 214 0441 300629 HCHG SW TX 38 TO 52 MIN 1 75.50 08/06/08 214 0441 300617 HCHG SP/LG TX 23 TO 37MIN 1 112.00 08/06/08 214 0441 300629 HCHG SW TX 38 TO 52 MIN 92.50 08/07/08 08/07/08 214 0441 300617 HCHG SP/LG TX 23 TO 37MIN i 112.00 50 92 08/08/08 214 214 0441 300629 HCHG SW TX 38 TO 52 MIN . 08/11/08 214 0441 0441 300618 300619 HCHG SP/LG TX 38 TO 52 MIN 1 137.50 08/11/08 214 0441 300633 HCHG SP/LG TX 53 TO 67 MIN HCHG SW TX 8 1 183.00 08/12/08 214 0441 300629 TO 22 MIN HCHG SW TX 38 TO 52 MIN 1 38.50 08/12/08 08/13/08 214 0441 300617 HCHG SP/LG TX 23 TO 37MIN i 112.00 92 50 *MS 214 0441 300617 HCHG SP/LG TX 23 TO 37MIN 1 . 92.50 08/13/08 214 0441 300633 HCHG SW TX 8 TO 22 MIN 1 38.50 08/14/08 08/15/08 214 214 0441 300619 HCHG SP/LG TX 53 TO 67 MIN 1 183.00 08/18/08 214 0441 0 300620 HCHG SP/LG TX 68 TO 82 MIN 1 227.50 08/19/08 214 441 0 300620 HCHG SP/LG TX 68 TO 82 MIN 1 227.50 08/20/08 214 441 0441 300619 HCHG SP/LG TX 53 TO 67 MIN 1 183.00 07/23/08 214 0444 300619 300612 HCHG HCHG SP/LG SP/LG TX 53 TO 67 EVAL MIN 1 183.00 08/12/08 131 0480 300388 HCHG DOPPLE 38 TO R F/U 52 M 1 137.50 08/12/08 131 0480 300389 HCHG COLOR FLOW DOPPLER 1 1 374.00 08/12/08 131 0480 300404 HCHG 2D M-MODE LIMITED F/U 1 374.00 07/22/08 506 0920 300728 429.50 08/21/08 506 0920 300728 1 0.00 1 0.00 Total for 322 Charges 28,034.68 Payments -----------------=====Amount ost Date Recd. From / /-------------------=====MEDICARE====__________------- __________________________ 10 13 08 -8,456.56 Total for 1 Payments Adjustments -8,456.56 ___________________________ ost Date Adj. For Amount / /-------------------=====MEDICARE====________________--- _____ _____ 10 13 08 -16,890.12 Total for 1 Adjustments Balance -16,890.12 2,688.00 *MS WSJ HOSPITALS PO BOX 1127 MORGANTOWN, WV 26057-1127 Ph: 304-598-4032 Guarantor Number Guarantor Name & Address 100128647 BUTTORFF,LOUISE 219 HALDERMAN AVE Account Number BAD ADDRESS 322394 NEW CUMBERLAND, PA 17070 Detailed Bill For Patient Name: BUTTORFF,LOUISE S Admission Date: 10/15/2008 Account Class: Inpatient Attending Physician: WEIMER, TRACY Discharge Date: 10/18/2008 Charges Service ---- Cost ------ Rev. --------- Proc. -----=====p=====____-------- Descri tion - _____ ___ Date Ctr. Code Code Qt Y• Amount 10/18/08 350 0022 300199 HCHG RUG'S - SE3 10/15/08 350 0120 100023 HCHG SNU ROOM 3 0.00 10/16/08 350 0120 100023 HCHG SNU ROOM 1 435.00 10/17/08 350 0120 100023 HCHG SNU ROOM 1 435.00 10/16/08 230 0250 110031 NORMAL SALIN E IV 10 1 435.00 10/16/08 10/16/08 230 230 0250 110034 VITAMIN A&D DINT 5G 1 1 3.26 3 2 10/16/08 230 0250 110034 VITAMIN A&D OINT 5G 1 . 6 3 2 10/16/08 230 0250 110034 VITAMIN A&D DINT 5G 1 . 6 3 2 10/16/08 23 0250 110034 VITAMIN A&D DINT 5G 1 . 6 3 10/16/08 0 23 0250 110034 ACETAMINOPHE N SUPP 1 .26 3 10/16/08 0 230 0250 110034 ACETAMINOPHE N SUPP 1 .26 3 10/16/08 230 0250 110034 ACETAMINOPHE N SUPP 1 .26 3 2 0250 110031 VALPROATE IN J . 6 10/16/08 230 0250 110031 LEVETIRACETA M INJ 1 26.28 10/16/08 230 0250 110031 VALPROATE IN J 2 157.30 10/16/08 230 0250 110031 LEVETIRACETA M INJ 1 26.28 10/16/08 230 0250 110031 VALPROATE 1N J 2 157.30 10/16/08 10/16/08 230 23 0250 110034 NYSTATIN LIQ 100000 1 1 26.28 3 10/16/08 0 23 0250 110031 LEVETIRACETA M INJ 2 .26 157 10/16/08 0 23 0250 110034 NYSTATIN LIQ 100000 1 .30 3 10/17/08 0 23 0250 110034 NYSTATIN LIQ 100000 1 .26 3 10/17/08 0 23 0250 110034 VITAMIN A&D OINT 5G 1 .26 3 10/17/08 0 23 0250 110031 NORMAL SALIN E IV 10 1 .26 3 10/17/08 0 23 0250 110034 ACETAMINOPHE N SUPP .26 3 10/17/08 0 23 0250 110031 MORPHINE (2M G/ML) I i .26 1 10/17/08 0 23 0250 110034 VITAMIN A&D DINT 5G 1 3.29 3 10/17/08 0 230 0250 110068 MORPHINE INJ 1 .26 13 10/17/08 23 0250 110068 MORPHINE INJ 1 .29 1 10/17/08 0 23 0250 110031 VALPROATE IN J 1 3.29 2 10/17/08 0 23 0250 110031 LEVETIRACETA M INJ 2 6.28 15 10/17/08 0 230 0250 110068 MORPHINE INJ 1 7.30 13 10/17/08 23 0250 110068 MORPHINE INJ 1 .29 10/17/08 0 23 0250 110031 LORAZEPAM (2 MG/ML) 1 13.29 10/17/08 0 230 0250 110068 MORPHINE INJ 1 10.11 13 *MS 0250 110034 NYSTATIN LIQ 100000 1 .29 3.26 10/17/os 10/17/08 10/17/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/15/08 10/16/08 10/16/08 10/18/08 10/16/08 10/16/08 10/16/08 10/16/08 10/16/08 10/16/08 10/16/08 10/16/08 10/16/08 10/17/08 10/17/08 10/17/08 10/17/08 10/17/08 10/17/08 10/17/08 10/17/08 10/17/08 10/17/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 10/18/08 230 230 230 230 230 230 230 230 230 230 230 230 230 230 230 230 230 230 230 230 201 230 230 230 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 506 0250 110034 0250 110034 0250 110034 0250 110034 0250 110034 0250 110034 0250 110034 0250 110034 0250 110031 0250 110031 0250 110031 0250 110031 0250 110031 0250 110031 0250 110031 0250 110034 0250 110034 0250 110034 0250 110034 0250 110034 0270 300139 0636 110208 0636 110208 0636 110208 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 0920 300729 Total for 86 Charges NYSTATIN LIQ 100000 NYSTATIN LIQ 100000 NYSTATIN LIQ 100000 VITAMIN A&D DINT 5G VITAMIN A&D DINT 5G VITAMIN A&D DINT 5G ACETAMINOPHE N SUPP ACETAMINOPHE N SUPP VALPROATE IN J LEVETIRACETA M INJ LORAZEPAM (2 MG/ML) LORAZEPAM (2 MG/ML) VALPROATE IN J LEVETIRACETA M INJ LORAZEPAM (2 MG/ML) NYSTATIN LIQ 100000 NYSTATIN LIQ 100000 NYSTATIN LIQ 100000 VITAMIN A&D DINT 5G ACETAMINOPHE N SUPP HCHG NASAL CANNULA - UNIT FOSPHENYTOIN INJ FOSPHENYTOIN INJ FOSPHENYTOIN INJ 1 3.26 1 3.26 1 3.26 1 3.26 1 3.26 1 3.26 1 3.26 1 3.26 1 26.28 2 157.30 1 10.11 1 10.11 1 26.28 2 157.30 1 10.11 1 3.26 1 3.26 1 3.26 1 3.26 1 3.26 1 76.00 6 179.76 6 179.76 6 179.76 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 1 0.00 3,236.48 *MS Payments _____________________________________________ Post Date ___________________________ Recd. From _____________________ Amount ________________________ ________________________ 12/18/08 MEDICARE ________________ -624.72 Total for 1 Payments -624.72 Adjustments _________________________________________________ ------------------ ost Date -------------------- ________________________________Aaj==For=====______________--- Amount 12/18/08 _____________________ MEDICARE -2,227.76 Total for 1 Adjustments -2,227.76 Balance 384.00 *MS