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Oregon Health Plan · Service date Jun 12, 2026 · Dr. Samuel Ortiz
MRN MRN-PAT-GEN-23 · 30 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 |
|---|---|---|---|---|---|---|---|
| Jun 12, 2026 | 72148 | — | R51.9 | 11 - Office | 1 | $1,800.00 | |
Allowed$1,188.00 Pri ins paym$1,069.20 Pri ins adj$612.00 Pat resp$118.80 Pat bal$118.80 Bal$118.80 | |||||||
| Check date | Check number | ERA ID |
|---|---|---|
| Jun 24, 2026 | OHP-520123 | era-20123 |
| Check date | Check number | Payer Claim ID |
|---|---|---|
| Jun 24, 2026 | OHP-520123 | — |
Date of service | Facility | Status | Billed |
|---|---|---|---|
Northstar Family Health - Main | ERA received | $650.00 | |
Northstar Family Health - Main | ERA review | $2,400.00 |