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City Health Medical Center
123 Medical Blvd Suite 400 Chicago, IL 60611 (312) 555-0123 [email protected] NPI: 9876543210
Receipt #: MED-2026-8841
3/24/2026 10:15:00 AM
1
General Physician Consultation (99213)
$125.00
1
Comprehensive Blood Panel (CBC)
$75.00
1
Urinalysis - Routine
$35.00
Subtotal
$235.00
Insurance Adjustment
$-45.00
Co-pay Paid
$-25.00
Total
$165.00
THANK YOU FOR TRUSTING CITY HEALTH Please keep this receipt for your insurance records. Visit www.cityhealth.com for portal access. Health is Wealth.