Melissa Insurance bill

	A	B	C	D	E	F
1		Physician Office Statement
2
3	Bill to:			Date:	_____________
4	Melissa Anderson
5	[Address]
6	[City, ST ZIP Code]
7	[Phone]
8
9	Physician	CPT Code	Cost	Times Administered	Cost	Notes
10	Office Visit, Established Patient, Level 5, High complexity, approximately 40 minutes	99215	$202.00	1	$202.00
11	Facility	CPT Code	Cost	Times Administered	Cost	Notes
12	Routine Physical	99215	$235.00	1	$235.00
13	Laboratory	CPT Code	Cost per Test	Times Administered	Cost	Notes
14	Complete Blood Count (CBC)	80061	$47.01	1	$47.01
15	Comprehensive Metabolic Panel (CMP)	85003	$43.99	1	$43.99
16	EBV Antibody Panel	80081	$168.00	1	$168.00
17	Pharmacy	Dose	Cost per Dose	Times Administered	Cost	Notes
18	Acetaminophen	325 mg	$0.61	28	$17.08	2 times a day for 14 days
19	Ibuprofen	400	$0.32	28	$8.96	2 times a day for 14 days
20
21				Amount Due	$722.04
22
23	@ Oracle Health Foundation
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100