Invoice Surgeon in United States Chicago –Free Word Template Download with AI
123 Medical Plaza Drive, Suite 400
Chicago, Illinois 60611
United States
Phone: (312) 555-0199 | Fax: (312) 555-0198
Email: [email protected]
Tax ID: 36-XXXXXXX
Invoice Number: INV-2023-8942
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Date: October 15, 2023
Bill ToBlue Cross Blue Shield of Illinois
P.O. Box 69000
Chicago, IL 60669
United States
Group Number: G-998877
Policy Number: P-123456789
Patient InformationName: Johnathan Doe
Date of Birth: 05/12/1980
Address: 456 Lake Shore Drive, Apt 12B
Chicago, IL 60611
Member ID: M-987654321
Surgical Services Rendered| Code | Description of Service | Qty | Unit Price | Total |
|---|---|---|---|---|
| 47562 | Laparoscopic cholecystectomy; with common duct exploration. Performed by Dr. Sarah Jenkins, Board-Certified Surgeon. | 1 | $4,500.00 | $4,500.00 |
| 99223 | Initial hospital care, per day, for the evaluation and management of a patient, who requires a moderately complicated or more detailed history, examination, and medical decision making. | 2 | $350.00 | $700.00 |
| 99238 | Subsequent hospital care, per day, for the evaluation and management of a patient, who requires a detailed interval history, detailed examination, and straightforward medical decision making. | 1 | $250.00 | $250.00 |
| 99239 | Subsequent hospital care, per day, for the evaluation and management of a patient, who requires a detailed interval history, detailed examination, and medical decision making of moderate complexity. | 1 | $300.00 | $300.00 |
| 99231 | Subsequent hospital care, per day, for the evaluation and management of a patient, who requires a problem focused interval history, problem focused examination, and straightforward medical decision making. | 1 | $150.00 | $150.00 |
| 99221 | Discharge day management; 30 minutes or less. Provided by the attending Surgeon. | 1 | $200.00 | $200.00 |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a detailed history, detailed examination, and medical decision making of moderate complexity. | 1 | $275.00 | $275.00 |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires an expanded problem focused history, expanded problem focused examination, and medical decision making of low complexity. | 1 | $180.00 | $180.00 |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a problem focused history, problem focused examination, and straightforward medical decision making. | 1 | $120.00 | $120.00 |
| 99211 | Office or other outpatient visit for the evaluation and management of an established patient, which may not require the presence of a physician or other qualified health care professional. | 1 | $80.00 | $80.00 |
| 99210 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a problem focused history, problem focused examination, and straightforward medical decision making. | 1 | $60.00 | $60.00 |
| 99209 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a problem focused history, problem focused examination, and straightforward medical decision making. | 1 | $100.00 | $100.00 |
| 99208 | Office or other outpatient visit for the evaluation and management of a new patient, which requires an expanded problem focused history, expanded problem focused examination, and medical decision making of low complexity. | 1 | $140.00 | $140.00 |
| 99207 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a detailed history, detailed examination, and medical decision making of moderate complexity. | 1 | $190.00 | $190.00 |
| 99206 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a comprehensive history, comprehensive examination, and medical decision making of high complexity. | 1 | $250.00 | $250.00 |
| 99205 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a comprehensive history, comprehensive examination, and medical decision making of high complexity. | 1 | $300.00 | $300.00 |
| 99204 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a detailed history, detailed examination, and medical decision making of moderate complexity. | 1 | $350.00 | $350.00 |
| 99203 | Office or other outpatient visit for the evaluation and management of a new patient, which requires an expanded problem focused history, expanded problem focused examination, and medical decision making of low complexity. | 1 | $400.00 | $400.00 |
| 99202 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a problem focused history, problem focused examination, and straightforward medical decision making. | 1 | $450.00 | $450.00 |
| 99201 | Office or other outpatient visit for the evaluation and management of a new patient, which requires a problem focused history, problem focused examination, and straightforward medical decision making. | 1 | $500.00 | $500.00 |
| 99199 | Unlisted evaluation and management service. | 1 | $550.00 | $550.00 |
| 99198 | Unlisted evaluation and management service. | 1 | $600.00 | $600.00 |
| 99197 | Unlisted evaluation and management service. | 1 | $650.00 | $650.00 |
| 99196 | Unlisted evaluation and management service. | 1 | $700.00 | $700.00 |
| 99195 | Unlisted evaluation and management service. | 1 | $750.00 | $750.00 |
| 99194 | Unlisted evaluation and management service. | 1 | $800.00 | $800.00 |
| 99193 | Unlisted evaluation and management service. | 1 | $850.00 | $850.00 |
| 99192 | Unlisted evaluation and management service. | 1 | $900.00 | $900.00 |
| 99191 | Unlisted evaluation and management service. | 1 | $950.00 | $950.00 |
| 99190 | Unlisted evaluation and management service. | 1 | $1,000.00 | $1,000.00 |
| Subtotal: | $15,000.00 |
| Tax (0%): | $0.00 |
| Total Due: | $15,000.00 |
Payment Terms and Notes
This invoice is issued by Chicago Surgical Specialists, a leading surgical practice located in the heart of Chicago, Illinois, United States. All surgical procedures were performed by board-certified surgeons adhering to the highest standards of medical care.
Payment is due within 30 days of the invoice date. Please include the invoice number (INV-2023-8942) with your payment. Payments can be made via check, wire transfer, or credit card. For questions regarding this invoice, please contact our billing department at (312) 555-0199.
This invoice is subject to the laws of the State of Illinois and the United States. Any disputes must be resolved in the jurisdiction of Chicago, Illinois.
Authorized Signature
Dr. Sarah Jenkins, MD
Chief Surgeon
Received By
_________________________
Date: ___________________
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