| 45952-9 | National provider ID:ID:Pt:Provider:Nom: | |
| 45952-9 | National provider ID:ID:Pt:Provider:Nom: | |
| 45952-9 | National provider ID:ID:Pt:Provider:Nom: | |
| 45952-9 | National provider ID:ID:Pt:Provider:Nom: | |
| 52829-9 | Place of service:Type:Pt:Facility:Nom: | |
| 52829-9 | Place of service:Type:Pt:Facility:Nom: | |
| 52829-9 | Place of service:Type:Pt:Facility:Nom: | |
| 52829-9 | Place of service:Type:Pt:Facility:Nom: | |
| 86255-7 | Primary Dx ICD code | |
| 86255-7 | Primary Dx ICD code | |
| 86255-7 | Primary Dx ICD code | |
| 86255-7 | Primary Dx ICD code | |
| 81885-6 | Dx.secondary | |
| 81885-6 | Dx.secondary | |
| 81885-6 | Dx.secondary | |
| 81885-6 | Dx.secondary | |
| 89266-1 | Proc+Serv+Supp code | |
| 89266-1 | Proc+Serv+Supp code | |
| 89266-1 | Proc+Serv+Supp code | |
| 89266-1 | Proc+Serv+Supp code | |
| 76430-8 | CPT units | |
| 76430-8 | CPT units | |
| 76430-8 | CPT units | |
| 76430-8 | CPT units | |
| 89265-3 | Proc+Serv+Supp mod | |
| 89265-3 | Proc+Serv+Supp mod | |
| 89265-3 | Proc+Serv+Supp mod | |
| 89265-3 | Proc+Serv+Supp mod | |
| 89178-8 | Financial responsibility | |
| 89178-8 | Financial responsibility | |
| 89178-8 | Financial responsibility | |
| 89178-8 | Financial responsibility | |
| 76428-2 | Visit charge | |
| 76428-2 | Visit charge | |
| 76428-2 | Visit charge | |
| 76428-2 | Visit charge | |