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Invoice #INV-2026-9041
Paid & SettledCardiology & 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)
Copay & Deductible
Paid & Cleared
Receipt #RCT-99201
Diagnostic & Billing Classification Codes (ICD-10 / CPT Mapping)
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
Itemized Medical Services & Line Items
| 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 |
Insurance Explanation of Benefits (EOB) & Payer Adjudication
BlueCross BlueShield Premier
Group Policy #BCBS-99482-A
#CLM-2026-5591
Approved on 16 Nov 2026
$960.00 Settled
EFT Ref #EFT-884920
Detailed Co-Insurance Breakdown
$50.00
$190.00
-$240.00
$240.00
Payment Transaction Log & Digital Receipts
| 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 |
Hospital Billing Terms & Financial Assistance Disclaimers
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).
Billing Healthcare Provider
Dreams General Hospital
100 Medical Center Drive, Suite 400
New York, NY 10001
100% HSA / FSA Qualified
This invoice includes official CPT coding compliant with IRS guidelines for Health Savings Account reimbursement.