Claims
Billed
$2,100.00
Allowed
$1,800.00
Approved
$1,300.00
Member Resp.
$500.00
Claim Details
- Provider
- Lakeside Family Medicine
- Service Date
- Mar 27, 2026
- Submitted
- Mar 28, 2026
- Auto-Adjudicated
- Yes
Member
Diagnosis Codes
M54.5— Low back pain(Principal)
Service Lines
| # | CPT | Description | Billed | Allowed | Approved | Member Resp. |
|---|---|---|---|---|---|---|
| 1 | 99204 | Office visit, new patient (level 4) | $350.00 | $210.00 | $210.00 | $140.00 |
| 2 | 97110 | Therapeutic exercises, 15 min | $120.00 | $42.00 | $42.00 | $78.00 |
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