Enclave

BrIgHT HARBOR PRIMARY CARE
27 Quayside Lane, Floor 3
Portland, ME 04101 | (207) 555-0119
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STATEMENT OF SERVICES / SUPERBIlL

PATIENT
   Name: Javier Rodriguez
  DOB: 2004-12-26
  MRN: MRN-9670403
  Phone: (494) 555-9212

ENCOUNTER
  Date of Service: 2026-01-l0
  Visit Type: Preventive Visit
  Rendering Provider: Funmilayo Bankole, DO
  NPI: 1526948370

DIAGNOSES
  1. Unspecified asthma, uncomplicated  [J45.909]

SErVICEs
  DESCRIPTION                                   CPT      QTY      CHARGE
  ---------------------------------------------------------------------
   complete blood count                          85025   1        $29.46
  new pt visit level 2                          99202   1       $106.38
  preventive exam,  established, 18-39           99395   2       $468.38
  injection admin                                96372   3        $90.54

  TOTAL DUE: $694.76

INSURAnCE / PAYER
  Plan: Cascade Benefit Group
  Member ID: JUD12149059