Claims
Billed
$4,500.00
Allowed
$3,800.00
Approved
$3,300.00
Member Resp.
$500.00
Claim Details
- Provider
- Dr. Sarah Mitchell
- Service Date
- Mar 15, 2026
- Submitted
- Mar 16, 2026
- Auto-Adjudicated
- Yes
Member
Diagnosis Codes
J06.9— Acute upper respiratory infection, unspecified(Principal)R05.9— Cough, unspecified
Service Lines
| # | CPT | Description | Billed | Allowed | Approved | Member Resp. |
|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient (level 4) | $250.00 | $165.00 | $165.00 | $85.00 |
| 2 | 80053 | Comprehensive metabolic panel | $150.00 | $22.00 | $22.00 | $128.00 |
| 3 | 71046 | Chest X-ray, 2 views | $300.00 | $55.00 | $55.00 | $245.00 |
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