TYPE: medical
DOCUMENT: itemized_bill
PROVIDER: The Mount Sinai Hospital
PHONE: (212) 555-0142
PROVIDER STATE: NY
ACCOUNT: 7730-0098-4412
STATEMENT DATE: 2026-09-02
DUE DATE: 2026-10-02
SERVICE DATE: 2026-08-14
INSURANCE: self-pay
LINE: 2026-08-14 | 99285 | Emergency room visit, level 5 | 1 | 2,450.00
LINE: 2026-08-14 | 70450 | CT head without contrast | 1 | 3,850.00
LINE: 2026-08-14 | 80053 | Comprehensive metabolic panel | 1 | 380.00
LINE: 2026-08-14 | 85025 | Complete blood count | 1 | 240.00
LINE: 2026-08-14 | 85025 | Complete blood count | 1 | 240.00
LINE: 2026-08-14 | 96374 | IV push, single drug | 1 | 520.00
LINE: 2026-08-14 | J2405 | Ondansetron injection | 4 | 96.00
LINE: 2026-08-14 | - | Pharmacy supplies miscellaneous | 1 | 310.00
TOTAL CHARGES: 8,086.00
AMOUNT DUE: 8,086.00