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Open settingsCardiology & Lab
Outpatient Visit
#EIN-94-882019
Card + Insurance
100% Settled
$0.00 (Cleared)
$1,200.00
Total Charges Before Insurance
$960.00
Primary Policy (80% Co-Pay)
$240.00
Copay & Deductible
Paid & Cleared
Receipt #RCT-99201
ICD-10-I10
Essential (Primary) Hypertension
ICD-10-R00.2
Palpitations & Tachycardia
Rev Code 0510
Outpatient Clinic Services
POS-11 (Physician Office)
Dreams Medical Center 4B
| Code | Service / Procedure Description | Dept | Qty | Unit Price | Subtotal |
|---|---|---|---|---|---|
| CPT-99214 | Detailed Outpatient Consultation Dr. Sarah Chen, MD (NPI: #198200192) · Cardiology Evaluation | Cardiology | 1 | $250.00 | $250.00 |
| CPT-93000 | 12-Lead Electrocardiogram (ECG) Diagnostic tracing & cardiologist report analysis | Diagnostics | 1 | $350.00 | $350.00 |
| CPT-80053 | Comprehensive Metabolic Panel (CMP) Automated clinical lab analyzer blood panel | Pathology Lab | 1 | $400.00 | $400.00 |
| HCPCS-J3490 | Cardiovascular Formulary Dispensation Atenolol 25mg Oral Tablets (90-day supply) | Pharmacy | 1 | $200.00 | $200.00 |
BlueCross BlueShield Premier
Group Policy #BCBS-99482-A
#CLM-2026-5591
Approved on 16 Nov 2026
$960.00 Settled
EFT Ref #EFT-884920
$50.00
$190.00
-$240.00
$240.00
| Receipt # | Transaction Date | Payment Method | Ref / Auth ID | Amount Paid |
|---|---|---|---|---|
| #RCT-99201 | 15 Nov 2026 · 10:45 AM | Visa ending 4921 | #AUTH-773921 | $240.00 |
| #RCT-EFT884 | 16 Nov 2026 · 02:15 PM | Payer EFT Transfer | #EFT-884920 | $960.00 |
Financial Assistance Policy (FAP): Dreams General Hospital provides compassionate financial assistance and sliding-scale fee discounts for eligible low-income patients. To apply for charity care, contact Patient Financial Services within 240 days of initial statement date.
HSA/FSA Tax Qualification: All itemized medical services listed above qualify as medical expenses under IRS Code Section 213(d) and are 100% eligible for reimbursement via Health Savings Accounts (HSA) or Flexible Spending Accounts (FSA).
Dreams General Hospital
100 Medical Center Drive, Suite 400
New York, NY 10001
This invoice includes official CPT coding compliant with IRS guidelines for Health Savings Account reimbursement.