Invoice Radiologist in United States Houston –Free Word Template Download with AI
1200 Smith Street, Suite 400
Houston, TX 77002, United States
Phone: (713) 555-0199 | Fax: (713) 555-0198
Email: [email protected]
TIN: 74-1234567
Invoice Number: INV-HOU-2023-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 15, 2023 - October 20, 2023
Bill To:
Memorial Hermann Health System
Attn: Accounts Payable Department
6411 Fannin Street
Houston, TX 77030, United States
Account Number: MH-REF-99201
Service Description:
This invoice represents professional fees for diagnostic radiology services rendered by board-certified Radiologists employed by Houston Advanced Radiology Associates. These services were provided to patients referred by Memorial Hermann Health System facilities located within the Greater Houston metropolitan area.
In accordance with the Medical Practice Act of Texas and federal regulations within the United States, all interpretations were performed by qualified specialists. The procedures listed below include the technical component (TC) and professional component (PC) as agreed upon in our facility contract. These services encompass advanced imaging modalities including Magnetic Resonance Imaging (MRI), Computed Tomography (CT), and specialized Ultrasound diagnostics.
As a premier radiology group in Houston, we adhere to the highest standards of patient care and diagnostic accuracy. The fees detailed herein reflect the complexity of the cases reviewed, the urgency of the reports generated (including after-hours and emergency consultations), and the specialized expertise required for oncological and neurological imaging prevalent in our region.
| Date | Description of Radiology Services | CPT Code | Units | Rate | Amount |
|---|---|---|---|---|---|
| Oct 15 | MRI Brain without contrast; interpretation by Senior Radiologist. | 70553 | 1 | $450.00 | $450.00 |
| Oct 16 | CT Chest with contrast; detailed oncological review. | 71260 | 1 | $380.00 | $380.00 |
| Oct 17 | Ultrasound Abdomen, Complete; focused on hepatobiliary system. | 76700 | 1 | $220.00 | $220.00 |
| Oct 18 | MRI Lumbar Spine with and without contrast; post-operative evaluation. | 72148 | 1 | $550.00 | $550.00 |
| Oct 19 | CT Abdomen and Pelvis with contrast; trauma protocol. | 74177 | 1 | $410.00 | $410.00 |
| Oct 20 | Mammography, Bilateral, Diagnostic; urgent consult. | 77065 | 1 | $300.00 | $300.00 |
| Oct 20 | Emergency After-Hours Consultation Fee (Radiologist On-Call). | 99291 | 2 | $150.00 | $300.00 |
Payment Terms:
Payment is due within 30 days of the invoice date. Please make checks payable to "Houston Advanced Radiology Associates" and mail to the address listed in the header. For electronic payments (ACH/Wire), please contact our accounts receivable department at (713) 555-0199 for routing details.
Important Notice: This invoice is generated in compliance with the healthcare billing standards of the United States. All CPT codes listed are current as of the 2023 coding set. If you have any questions regarding the services provided by our Radiologists or the charges listed, please reference the Invoice Number INV-HOU-2023-8842 when contacting us. Late payments may be subject to a 1.5% monthly finance charge as per our service agreement.
Authorized Signature:
Dr. James A. Sterling, MD
Chief of Radiology
Houston Advanced Radiology Associates
Received By:
__________________________
Date: ____________________
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT