Using the information provided complete the superbill template showing all charges incurred during Christines visit. Make sure to update the patient account with the co-payment of $ 45.00 that she made at the time of the visit.

GUARANTOR: Name Address Phone Visit # Patient Name Age D.O.B Provider Patient Name of Insurance S.S.N. Co-Pay Date PRED HE OFFICE NEW FEE ESTAB. FEE OTHER CHARGES CONSULTATION Complete Physical NEW FEE ESTAB.FEE ER Visit 99058 =15 = 17111 A4550 Surgical Tray 83735 Magnesium Berian Premalimat Lesion Tre AK (cryo, etc) 99070 Peak Flow Meter 84550 Uric Acid Lesion 1 - 17000 Lesions 2-14-17001 L3800 Finger Splint 88150 Pap Trigger Point Injection 20550 88142 Thin Preppen Nail Removal 11730 IMMUNIZATION ADMINISTRATION 87800 GC Chamy: DNA Probe Aspiration Cyst 10160 90471 90472x 87252-87274 Herpes Culture Agparation Toint 20600 90702 DT (child) 00634 Hep A (child) 86703 HIV I&D Abscess - Simple Single 10060 90718 T (Adult Tetamus) 90632 Hep A (adult) 86592 RPRAVDRL I&D Abscess - Complicated Mary 10061 00200 DTD 00744 Hep B (Birth - Il yo) 80074 Hepatitis Panel Endometrial Big $100 2012 DTD and Hib 90745. AB (11-19 yo) 85025 CBC Complete Colposcopy w Bx 57454 wout Bx 57452 00669 Dretar (Cani-Preumo) 0074 Hep B (>20 yo) 00707 MR. (Live) 00650 infrenta 85651 Sed Rate 00732 Premontas (schult) 90713 Poliomyelitis (inject) 83540 Iron 82728 Ferritin Skin T22 Removal 4.0cm 90782 84443 TSH Site: face, ears, eyelids, nose, lips 84481 Free T's scalp. neck, hands, feet, genitalia 81000 Urine Dip trunk, amm. leg 81001 Urinalysis *** Hold for Pathology *** BILLING INFORMATION 87088 Urine Culture LACERATIONS BALANCE FORWARD 87890 Rapid Strep Test Scalp, Neck Trunk Arms, Feet TODAY'S CHARGES 87070 Strep Culture Simple Intermediate ADJUSTMENTS 86308 Mono Spot 0.5 cm 12001 12031 84703 Pregnancy (Serum) 2.6-7.5 cm 12002 PAID ON ACCOUNT 81025 Pregnancy (Urine) 7.6-12.5 cm 12004 12034 VISA OMCO CHECK CASH 87045 Stool Culture 0-2.5 cm 12041 2.6-7.5 cm 87186 Sensitivity 12042 TOTAL DUE 87210 Wet prep Fecal WBC's 7.8-125 cm 12044 87177 O&P x Face. Ears, Eves, Nose, Lips 87328 Giardia-ELA Simple Intemediate PHYSICIAN'S SIGNATURE 87230 C. difficile toim 0-25 cm 12011 12051 86677 H Plori 2.6-5.0 cm 12013 12052 85610 PT/INR 85670 PIT 5.0-75 cm 12014 12053 RETURN VISIT ON 12032 GUARANTOR: Name Address Phone Visit # Patient Name Age D.O.B Provider Patient Name of Insurance S.S.N. Co-Pay Date PRED HE OFFICE NEW FEE ESTAB. FEE OTHER CHARGES CONSULTATION Complete Physical NEW FEE ESTAB.FEE ER Visit 99058 =15 = 17111 A4550 Surgical Tray 83735 Magnesium Berian Premalimat Lesion Tre AK (cryo, etc) 99070 Peak Flow Meter 84550 Uric Acid Lesion 1 - 17000 Lesions 2-14-17001 L3800 Finger Splint 88150 Pap Trigger Point Injection 20550 88142 Thin Preppen Nail Removal 11730 IMMUNIZATION ADMINISTRATION 87800 GC Chamy: DNA Probe Aspiration Cyst 10160 90471 90472x 87252-87274 Herpes Culture Agparation Toint 20600 90702 DT (child) 00634 Hep A (child) 86703 HIV I&D Abscess - Simple Single 10060 90718 T (Adult Tetamus) 90632 Hep A (adult) 86592 RPRAVDRL I&D Abscess - Complicated Mary 10061 00200 DTD 00744 Hep B (Birth - Il yo) 80074 Hepatitis Panel Endometrial Big $100 2012 DTD and Hib 90745. AB (11-19 yo) 85025 CBC Complete Colposcopy w Bx 57454 wout Bx 57452 00669 Dretar (Cani-Preumo) 0074 Hep B (>20 yo) 00707 MR. (Live) 00650 infrenta 85651 Sed Rate 00732 Premontas (schult) 90713 Poliomyelitis (inject) 83540 Iron 82728 Ferritin Skin T22 Removal 4.0cm 90782 84443 TSH Site: face, ears, eyelids, nose, lips 84481 Free T's scalp. neck, hands, feet, genitalia 81000 Urine Dip trunk, amm. leg 81001 Urinalysis *** Hold for Pathology *** BILLING INFORMATION 87088 Urine Culture LACERATIONS BALANCE FORWARD 87890 Rapid Strep Test Scalp, Neck Trunk Arms, Feet TODAY'S CHARGES 87070 Strep Culture Simple Intermediate ADJUSTMENTS 86308 Mono Spot 0.5 cm 12001 12031 84703 Pregnancy (Serum) 2.6-7.5 cm 12002 PAID ON ACCOUNT 81025 Pregnancy (Urine) 7.6-12.5 cm 12004 12034 VISA OMCO CHECK CASH 87045 Stool Culture 0-2.5 cm 12041 2.6-7.5 cm 87186 Sensitivity 12042 TOTAL DUE 87210 Wet prep Fecal WBC's 7.8-125 cm 12044 87177 O&P x Face. Ears, Eves, Nose, Lips 87328 Giardia-ELA Simple Intemediate PHYSICIAN'S SIGNATURE 87230 C. difficile toim 0-25 cm 12011 12051 86677 H Plori 2.6-5.0 cm 12013 12052 85610 PT/INR 85670 PIT 5.0-75 cm 12014 12053 RETURN VISIT ON 12032