Claims
Billed
$850.00
Allowed
$720.00
Approved
$720.00
Member Resp.
$130.00
Claim Details
- Provider
- Dr. Michael Torres
- Service Date
- Mar 20, 2026
- Submitted
- Mar 21, 2026
- Auto-Adjudicated
- Yes
Member
Diagnosis Codes
Z00.00— Encounter for general adult medical examination(Principal)
Service Lines
| # | CPT | Description | Billed | Allowed | Approved | Member Resp. |
|---|---|---|---|---|---|---|
| 1 | 99213 | Office visit, established patient (level 3) | $180.00 | $110.00 | $110.00 | $70.00 |
| 2 | 85025 | Complete blood count (CBC) | $45.00 | $15.00 | $15.00 | $30.00 |
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