Ahmed's MHSM Bill

	A	B	C	D	E
1		Emergency Department Statement
2		Emergency Department Statement
3	HITECH Medical Center			Date:
4
5
6	Bill to:
7
8	Ahmed Patel
9	[Address]
10	[City, ST ZIP Code]
11	[Phone]
12
13	ED Charges: Ahmed was in the ED for 4 hours before being discharged.
14
15	Physician	CPT Code	Cost	Time in ED	Total Cost
16	Critical Care Physician, First 30-74 minutes				$0.00
17	Critical Care Physician, Each 30 min, until discharge				$0.00
18	Facility	CPT Code	Cost	Time in ED	Total Cost
19	Intermediate Care Room and Board				$0.00
20	Intubation				$0.00
21	Ventilator Management				$0.00
22	Arterial Line Insertion (& Monitoring)				$0.00
23	SpO2 Pulse Oximeter, single reading				$0.00
24	Laboratory	CPT Code	Cost Per Test	Total Test Administered	Total Cost
25	Complete Blood Count (CBC) w/ WBC				$0.00
26	Liver Panel				$0.00
27	Blood Alcohol Content (BAC) - part of Drug Screening				$0.00
28	Lipid Panel (Profile)				$0.00
29	Basic Metabolic Panel (BMP)				$0.00
30	Radiology & Diagnostic Imaging	CPT Code	Cost Per Test	Total Test Administered	Total Cost
31	X-ray, Chest, 4 Views				$0.00
32	Reading & Interpretation				$0.00
33	Head/brain CT Scan, w/o contrast				$0.00
34	Reading & Interpretation				$0.00
35	Pharmacy	Dose	Cost Per Dose	Number of Units	Total Cost
36	Zofran (8 mg)				$0.00
37	Fentanyl (200 mcg)				$0.00
38	Lidocaine (115 mg)				$0.00
39	Banana Bag (1 L fluid over 4 hours)				$0.00
40
41				Amount Due	$0.00
42	@ Oracle Health Foundation \| August 2024
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