123 Business Street
City, State 12345
Phone: (555) 123-4567
Invoice #5883
Date: 11/2/2025
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| Description | Quantity | Rate | Amount |
|---|---|---|---|
| CPT/ICD-10 codes auto-suggested | 1 | $500.00 | $500.00 |
| Code lookup integrated into form | 2 | $150.00 | $300.00 |
| Subtotal: | $800.00 |
| Tax (8.5%): | $68.00 |
| TOTAL DUE: | $868.00 |