Super invoice

HOPE SUPER INVOICE

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$5000.00

Invoice IDs (1232, A44343, D32321)

$2000.00

Insurance paid

$3000.00

Balance you owe

Date of svc Invoice # CPT Code ICD Service Adjust Charges
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 1 2019 1232 99284 G35 ER Evaluation $100 $200
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 1 2019 1232 99223 G35 PHYS INIT. CONSULT $200 $500
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 1 2019 1232 99220 G35 INIT OBSV. $100 $300
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 1 2019 A44343 99211 G35 ROOM CHARGE SEMI $1300 $2,000
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 1 2019 A44343 J2930 G35 METHYLPREDNIS $0 $300
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 1 2019 A44343 36640 G35 INF THERAPY $100 $400
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 1 2019 A44343 36641 G35 INF THERAPY, ADDNL $50 $100
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 1 2019 A44343 99070 G35 SPECIAL SUPPLIES PHYS/QHP $100 $200
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 2 2019 D32321 99211 G35 ROOM CHARGE SEMI $0 $400
Date of svc Invoice # CPT Code ICD Service Adjust Charges
June 2 2019 D32321 99236 G35 PHYS OBVS $50 $600