|
{ |
|
"</s_$CHARGES 1>": 57643, |
|
"</s_$CHARGES 2>": 57667, |
|
"</s_$CHARGES 3>": 57691, |
|
"</s_1. INSURED PLAN>": 57799, |
|
"</s_1.INSURED PLAN>": 57797, |
|
"</s_10. PATIENT'S CONDITION>": 57789, |
|
"</s_10a. EMPLOYMENT>": 57791, |
|
"</s_10b. AUTO ACCIDENT>": 57793, |
|
"</s_10c. OTHER ACCIDENT>": 57795, |
|
"</s_11. INSURED'S POLICY GROUP OR FECA NUMBER>": 57787, |
|
"</s_11a. INSURED'S SEX>": 57785, |
|
"</s_11c. INSURANCE PLAN NAME>": 57783, |
|
"</s_11d. IS THERE ANOTHER HEALTH BENEFIT PLAN>": 57781, |
|
"</s_12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE>": 57779, |
|
"</s_13. INSURED OR AUTHORIZED PERSON'S SIGNATURE>": 57777, |
|
"</s_17>": 57801, |
|
"</s_1a. INSURED'S I.D. NUMBER>": 57775, |
|
"</s_2. PATIENT'S NAME>": 57773, |
|
"</s_20. LAB $CHARGES>": 57727, |
|
"</s_20. OUTSIDE LAB>": 57725, |
|
"</s_21. DIAGNOSIS OR NATURE OF ILLNESS>": 57697, |
|
"</s_22. RESUBMISSION CODE>": 57695, |
|
"</s_23. PRIOR AUTHORIZATION NUMBER>": 57693, |
|
"</s_24. SERVICES>": 57619, |
|
"</s_25. FEDERAL IDENTIFICATION>": 57617, |
|
"</s_25. FEDERAL TAX I.D. NUMBER>": 57615, |
|
"</s_26. PATIENT'S ACCOUNT NUMBER>": 57613, |
|
"</s_27. ACCEPT ASSIGNMENT>": 57611, |
|
"</s_28. TOTAL CHARGE>": 57609, |
|
"</s_29. AMOUNT PAID>": 57607, |
|
"</s_3. PATIENT'S DATE OF BIRTH>": 57765, |
|
"</s_3. PATIENT'S SEX>": 57763, |
|
"</s_31. PHYSICIAN OR SUPPLIER SIGNATURE>": 57601, |
|
"</s_32. SERVICE FACILITY LOCATION>": 57597, |
|
"</s_32. SERVICE INFORMATION>": 57595, |
|
"</s_32. a. NPI NUMBER>": 57599, |
|
"</s_33. BILLING INFORMATION>": 57587, |
|
"</s_33. BILLING PROVIDER LOCATION>": 57591, |
|
"</s_33. BILLING PROVIDER PHONE>": 57589, |
|
"</s_33. a. NPI NUMBER>": 57593, |
|
"</s_4. INSURED'S NAME>": 57739, |
|
"</s_5. PATIENT'S ADDRESS>": 57761, |
|
"</s_5. PATIENT'S CITY>": 57759, |
|
"</s_5. PATIENT'S STATE>": 57757, |
|
"</s_5. PATIENT'S TELEPHONE>": 57755, |
|
"</s_5. PATIENT'S ZIP CODE>": 57753, |
|
"</s_6. PATIENT RELATIONSHIP>": 57751, |
|
"</s_7. INSURED'S ADDRESS>": 57741, |
|
"</s_7. INSURED'S CITY>": 57745, |
|
"</s_7. INSURED'S INFO>": 57737, |
|
"</s_7. INSURED'S STATE>": 57743, |
|
"</s_7. INSURED'S TELEPHONE>": 57749, |
|
"</s_7. INSURED'S ZIP CODE>": 57747, |
|
"</s_9. OTHER INSURED'S NAME>": 57735, |
|
"</s_9a. OTHER INSURED'S POLICY OR GROUP>": 57733, |
|
"</s_9d. INSURANCE PLAN NAME>": 57731, |
|
"</s_CPT/HCPCS 1>": 57641, |
|
"</s_CPT/HCPCS 2>": 57665, |
|
"</s_CPT/HCPCS 3>": 57689, |
|
"</s_DATE>": 57605, |
|
"</s_DD 1>": 57639, |
|
"</s_DD 2>": 57663, |
|
"</s_DD 3>": 57687, |
|
"</s_DD>": 57771, |
|
"</s_DIAGNOSIS POINTER 1>": 57637, |
|
"</s_DIAGNOSIS POINTER 2>": 57661, |
|
"</s_DIAGNOSIS POINTER 3>": 57685, |
|
"</s_EMG 1>": 57635, |
|
"</s_EMG 2>": 57659, |
|
"</s_EMG 3>": 57683, |
|
"</s_Family Plan 1>": 57633, |
|
"</s_Family Plan 2>": 57657, |
|
"</s_Family Plan 3>": 57681, |
|
"</s_ILLNESS A.>": 57719, |
|
"</s_ILLNESS B.>": 57717, |
|
"</s_ILLNESS C.>": 57715, |
|
"</s_ILLNESS D.>": 57713, |
|
"</s_ILLNESS E.>": 57723, |
|
"</s_ILLNESS F.>": 57721, |
|
"</s_MM 1>": 57631, |
|
"</s_MM 2>": 57655, |
|
"</s_MM 3>": 57679, |
|
"</s_MM>": 57769, |
|
"</s_MODIFIER 1>": 57629, |
|
"</s_MODIFIER 2>": 57653, |
|
"</s_MODIFIER 3>": 57677, |
|
"</s_PATIENT AND INSURED INFORMATION>": 57729, |
|
"</s_PHYSICIAN OR MEDICAL PROVIDER INFORMATION>": 57585, |
|
"</s_PLACE OF SERVICE 1>": 57627, |
|
"</s_PLACE OF SERVICE 2>": 57651, |
|
"</s_PLACE OF SERVICE 3>": 57675, |
|
"</s_PROVIDER ID 1>": 57625, |
|
"</s_PROVIDER ID 2>": 57649, |
|
"</s_PROVIDER ID 3>": 57673, |
|
"</s_SIGNED>": 57603, |
|
"</s_UNITS 1>": 57623, |
|
"</s_UNITS 2>": 57647, |
|
"</s_UNITS 3>": 57671, |
|
"</s_YY 1>": 57621, |
|
"</s_YY 2>": 57645, |
|
"</s_YY 3>": 57669, |
|
"</s_YY>": 57767, |
|
"</s_cashprice>": 57549, |
|
"</s_changeprice>": 57551, |
|
"</s_cnt>": 57529, |
|
"</s_creditcardprice>": 57563, |
|
"</s_discount_price>": 57557, |
|
"</s_discountprice>": 57567, |
|
"</s_emoneyprice>": 57569, |
|
"</s_etc>": 57541, |
|
"</s_formtype>": 57583, |
|
"</s_itemsubtotal>": 57577, |
|
"</s_label>": 57711, |
|
"</s_menu>": 57525, |
|
"</s_menuqty_cnt>": 57555, |
|
"</s_menutype_cnt>": 57553, |
|
"</s_meta>": 57581, |
|
"</s_nm>": 57527, |
|
"</s_normalizedVertices>": 57703, |
|
"</s_num>": 57565, |
|
"</s_othersvc_price>": 57573, |
|
"</s_price>": 57531, |
|
"</s_service_price>": 57537, |
|
"</s_sub>": 57547, |
|
"</s_sub_total>": 57533, |
|
"</s_subtotal_price>": 57535, |
|
"</s_tax_price>": 57539, |
|
"</s_text>": 57709, |
|
"</s_total>": 57543, |
|
"</s_total_etc>": 57561, |
|
"</s_total_price>": 57545, |
|
"</s_unitprice>": 57559, |
|
"</s_vatyn>": 57575, |
|
"</s_void_menu>": 57571, |
|
"</s_word>": 57701, |
|
"</s_words>": 57699, |
|
"</s_x>": 57707, |
|
"</s_y>": 57705, |
|
"<s_$CHARGES 1>": 57642, |
|
"<s_$CHARGES 2>": 57666, |
|
"<s_$CHARGES 3>": 57690, |
|
"<s_1. INSURED PLAN>": 57798, |
|
"<s_1.INSURED PLAN>": 57796, |
|
"<s_10. PATIENT'S CONDITION>": 57788, |
|
"<s_10a. EMPLOYMENT>": 57790, |
|
"<s_10b. AUTO ACCIDENT>": 57792, |
|
"<s_10c. OTHER ACCIDENT>": 57794, |
|
"<s_11. INSURED'S POLICY GROUP OR FECA NUMBER>": 57786, |
|
"<s_11a. INSURED'S SEX>": 57784, |
|
"<s_11c. INSURANCE PLAN NAME>": 57782, |
|
"<s_11d. IS THERE ANOTHER HEALTH BENEFIT PLAN>": 57780, |
|
"<s_12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE>": 57778, |
|
"<s_13. INSURED OR AUTHORIZED PERSON'S SIGNATURE>": 57776, |
|
"<s_17>": 57800, |
|
"<s_1a. INSURED'S I.D. NUMBER>": 57774, |
|
"<s_2. PATIENT'S NAME>": 57772, |
|
"<s_20. LAB $CHARGES>": 57726, |
|
"<s_20. OUTSIDE LAB>": 57724, |
|
"<s_21. DIAGNOSIS OR NATURE OF ILLNESS>": 57696, |
|
"<s_22. RESUBMISSION CODE>": 57694, |
|
"<s_23. PRIOR AUTHORIZATION NUMBER>": 57692, |
|
"<s_24. SERVICES>": 57618, |
|
"<s_25. FEDERAL IDENTIFICATION>": 57616, |
|
"<s_25. FEDERAL TAX I.D. NUMBER>": 57614, |
|
"<s_26. PATIENT'S ACCOUNT NUMBER>": 57612, |
|
"<s_27. ACCEPT ASSIGNMENT>": 57610, |
|
"<s_28. TOTAL CHARGE>": 57608, |
|
"<s_29. AMOUNT PAID>": 57606, |
|
"<s_3. PATIENT'S DATE OF BIRTH>": 57764, |
|
"<s_3. PATIENT'S SEX>": 57762, |
|
"<s_31. PHYSICIAN OR SUPPLIER SIGNATURE>": 57600, |
|
"<s_32. SERVICE FACILITY LOCATION>": 57596, |
|
"<s_32. SERVICE INFORMATION>": 57594, |
|
"<s_32. a. NPI NUMBER>": 57598, |
|
"<s_33. BILLING INFORMATION>": 57586, |
|
"<s_33. BILLING PROVIDER LOCATION>": 57590, |
|
"<s_33. BILLING PROVIDER PHONE>": 57588, |
|
"<s_33. a. NPI NUMBER>": 57592, |
|
"<s_4. INSURED'S NAME>": 57738, |
|
"<s_5. PATIENT'S ADDRESS>": 57760, |
|
"<s_5. PATIENT'S CITY>": 57758, |
|
"<s_5. PATIENT'S STATE>": 57756, |
|
"<s_5. PATIENT'S TELEPHONE>": 57754, |
|
"<s_5. PATIENT'S ZIP CODE>": 57752, |
|
"<s_6. PATIENT RELATIONSHIP>": 57750, |
|
"<s_7. INSURED'S ADDRESS>": 57740, |
|
"<s_7. INSURED'S CITY>": 57744, |
|
"<s_7. INSURED'S INFO>": 57736, |
|
"<s_7. INSURED'S STATE>": 57742, |
|
"<s_7. INSURED'S TELEPHONE>": 57748, |
|
"<s_7. INSURED'S ZIP CODE>": 57746, |
|
"<s_9. OTHER INSURED'S NAME>": 57734, |
|
"<s_9a. OTHER INSURED'S POLICY OR GROUP>": 57732, |
|
"<s_9d. INSURANCE PLAN NAME>": 57730, |
|
"<s_CPT/HCPCS 1>": 57640, |
|
"<s_CPT/HCPCS 2>": 57664, |
|
"<s_CPT/HCPCS 3>": 57688, |
|
"<s_DATE>": 57604, |
|
"<s_DD 1>": 57638, |
|
"<s_DD 2>": 57662, |
|
"<s_DD 3>": 57686, |
|
"<s_DD>": 57770, |
|
"<s_DIAGNOSIS POINTER 1>": 57636, |
|
"<s_DIAGNOSIS POINTER 2>": 57660, |
|
"<s_DIAGNOSIS POINTER 3>": 57684, |
|
"<s_EMG 1>": 57634, |
|
"<s_EMG 2>": 57658, |
|
"<s_EMG 3>": 57682, |
|
"<s_Family Plan 1>": 57632, |
|
"<s_Family Plan 2>": 57656, |
|
"<s_Family Plan 3>": 57680, |
|
"<s_ILLNESS A.>": 57718, |
|
"<s_ILLNESS B.>": 57716, |
|
"<s_ILLNESS C.>": 57714, |
|
"<s_ILLNESS D.>": 57712, |
|
"<s_ILLNESS E.>": 57722, |
|
"<s_ILLNESS F.>": 57720, |
|
"<s_MM 1>": 57630, |
|
"<s_MM 2>": 57654, |
|
"<s_MM 3>": 57678, |
|
"<s_MM>": 57768, |
|
"<s_MODIFIER 1>": 57628, |
|
"<s_MODIFIER 2>": 57652, |
|
"<s_MODIFIER 3>": 57676, |
|
"<s_PATIENT AND INSURED INFORMATION>": 57728, |
|
"<s_PHYSICIAN OR MEDICAL PROVIDER INFORMATION>": 57584, |
|
"<s_PLACE OF SERVICE 1>": 57626, |
|
"<s_PLACE OF SERVICE 2>": 57650, |
|
"<s_PLACE OF SERVICE 3>": 57674, |
|
"<s_PROVIDER ID 1>": 57624, |
|
"<s_PROVIDER ID 2>": 57648, |
|
"<s_PROVIDER ID 3>": 57672, |
|
"<s_SIGNED>": 57602, |
|
"<s_UNITS 1>": 57622, |
|
"<s_UNITS 2>": 57646, |
|
"<s_UNITS 3>": 57670, |
|
"<s_YY 1>": 57620, |
|
"<s_YY 2>": 57644, |
|
"<s_YY 3>": 57668, |
|
"<s_YY>": 57766, |
|
"<s_cashprice>": 57550, |
|
"<s_changeprice>": 57552, |
|
"<s_cnt>": 57530, |
|
"<s_cord-v2>": 57579, |
|
"<s_creditcardprice>": 57564, |
|
"<s_discount_price>": 57558, |
|
"<s_discountprice>": 57568, |
|
"<s_emoneyprice>": 57570, |
|
"<s_etc>": 57542, |
|
"<s_formtype>": 57582, |
|
"<s_iitcdip>": 57523, |
|
"<s_itemsubtotal>": 57578, |
|
"<s_label>": 57710, |
|
"<s_menu>": 57526, |
|
"<s_menuqty_cnt>": 57556, |
|
"<s_menutype_cnt>": 57554, |
|
"<s_meta>": 57580, |
|
"<s_nm>": 57528, |
|
"<s_normalizedVertices>": 57702, |
|
"<s_num>": 57566, |
|
"<s_othersvc_price>": 57574, |
|
"<s_price>": 57532, |
|
"<s_service_price>": 57538, |
|
"<s_sub>": 57548, |
|
"<s_sub_total>": 57534, |
|
"<s_subtotal_price>": 57536, |
|
"<s_synthdog>": 57524, |
|
"<s_tax_price>": 57540, |
|
"<s_text>": 57708, |
|
"<s_total>": 57544, |
|
"<s_total_etc>": 57562, |
|
"<s_total_price>": 57546, |
|
"<s_unitprice>": 57560, |
|
"<s_vatyn>": 57576, |
|
"<s_void_menu>": 57572, |
|
"<s_word>": 57700, |
|
"<s_words>": 57698, |
|
"<s_x>": 57706, |
|
"<s_y>": 57704, |
|
"<sep/>": 57522 |
|
} |
|
|