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Exhibit 4 - Northwestern Medicine - Bills

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Utkarsh Singh
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91 views1 page

Exhibit 4 - Northwestern Medicine - Bills

Uploaded by

Utkarsh Singh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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M Medicine

Northwestern
Medicine Customer Service: 1-855-694-2866
Hours: 8:00 AM - 5:00 PM Mon-Fri
Office Hours:

Guarantor ID:
Guarantor
Statement Date: 06/01/23
0
VisitCoverages:
Visit Coverages:
LiabilityGeneric - LiabilityGeneric

Itemization of your hospital services for:


This is not a bill. This is an itemization

Patient: Admission Date: 05/15/23


Hospital Account: Discharge Date: 05/16/23

Current Hospital Account Balance: 9,004.50

Hospital Charges
CPT©/HCPCS Description
Service Date Revenue CPT©/HCPCS Quantity Amount
Code Code
05/15/2023 0300 36415 HB VENIPUNCTURE
VENIPUNCTURE 1 66.00
05/15/2023 0301 80053 HB COMPREHENSIVE METABOLIC PANEL 1 390.00
05/15/2023 0301 84703 HB CHRONIONIC GONADOTROPIN QUAL
CHRONIONIC GONADOTROPIN 1 195.00
05/15/2023 0305 85025 HB CBC WITH DIFFERENTIAL
DIFFERENTIAL 1 151.00
151,00
05/15/2023 0320 72100 HB X-RAYEXAML-S SPINE 2/3 VWS 1 813.00
05/15/2023 0352 72125 HB CT NECK SPINE W/O DYE 1 3,953.00
05/15/2023 0450 99285 HB ED VISIT LEVEL 5 1 3,183.00
05/15/2023 0636 J1885 KETOROLAC 15 MG/MLSOLUTION 1 3,50
3.50
05/15/2023 0940 96372 HB THER/PROPH/DIAG INJ SC/IM 1 250.00
Total hospital charges: 9,004.50
Total hospital payments and adjustments:

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