Claims
Billed
$1,200.00
Allowed
$950.00
Approved
$0.00
Member Resp.
$1,200.00
Claim Details
- Provider
- Metro Urgent Care
- Service Date
- Mar 25, 2026
- Submitted
- Mar 26, 2026
- Auto-Adjudicated
- No
- Denial Reason
- Service not eligible under tobacco attestation failure
Member
Diagnosis Codes
M75.10— Rotator cuff syndrome, unspecified shoulder(Principal)
Service Lines
| # | CPT | Description | Billed | Allowed | Approved | Member Resp. |
|---|---|---|---|---|---|---|
| 1 | 99215 | Office visit, established patient (level 5) | $350.00 | $225.00 | $0.00 | $350.00 |
| 2 | 73030 | Shoulder X-ray, 2+ views | $180.00 | $48.00 | $0.00 | $180.00 |
Adjudication Trace
Fee schedule lookup
Eligibility check
Tobacco surcharge applied
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