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Cigna · Service date Oct 20, 2026 · Dr. Hannah Cole
MRN MRN-PAT-GEN-16 · 26 yrs
Credentialing status unavailable for this provider.
Encounter-level place of service is the code on Box 24B of the CMS-1500. Per-line overrides appear in the Service lines table below.
| Date of service | CPT code | Modifiers | Diagnoses | Place of service | Qty | Billed | Details |
|---|---|---|---|---|---|---|---|
| Oct 20, 2026 | 80053 | — | M25.561 | 11 - Office | 1 | $45.00 | |
Allowed$29.70 Pri ins paym$26.73 Pri ins adj$15.30 Pat resp$2.97 Pat bal$2.97 Bal$2.97 | |||||||
| Check date | Check number | ERA ID |
|---|---|---|
| Nov 1, 2026 | CIG-520087 | era-20087 |
| Check date | Check number | Payer Claim ID |
|---|---|---|
| Nov 1, 2026 | CIG-520087 | — |
Date of service | Facility | Status | Billed |
|---|---|---|---|
Northstar Family Health - Main | Paid | $2,200.00 | |
Northstar Family Health - Main | Submitted | $2,400.00 | |
Northstar Family Health - Main | Rejected | $420.00 | |
Northstar Family Health - Main | ERA received | $650.00 | |
Northstar Family Health - Main | Paid | $4,800.00 | |
Northstar Family Health - Main | Paid | $230.00 |