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3-Oct NULL EVERETTE ANNIE EVERETTE, ANNTE
3-Oct UB70 Pat/Reason DX_A R0789
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10-Oct UB10 Patient DOB 09161992 091871992
14-Oct UB52_01_02 ROI B Y
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14-Oct UB53_01_02 ASG_BEN B Y
14-Oct UB39 A_02 Value Amount 1504.00 15.04
15-Oct UB47_01_02 Line Charge 212175
16-Oct UB66 DX_Cd_00 0
18-Oct UB47_TOTCHG 446.00
28-Oct UB53_01_01 ASG_BEN A Y
29-Oct UB67 C Other Diag C I071
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13-Nov UB51_01_01 Health Plan / Prov No A 00000245200
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21-Sep UB03 A Pat Control Number H2100046437700
21-Sep UB09 04 Patient Zipcode Ext 5727
21-Sep UB42_01_04 Revenue Code 336
21-Sep UB48 Non Covered Charge_04
21-Sep UB70 Pat/Reason DX_B
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21-Sep UB38_01 Insured Org Name FORREST T JONES
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23-Sep UB32 A Occurrence Code
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23-Sep UB42_01_04 Revenue Code
23-Sep UB45_01_04 Service Date
23-Sep UB48 Non Covered Charge_06
23-Sep NULL ROTAN, ALICE E
24-Sep UB46_01_02 Units 64
25-Sep UB14 Admission Type 1
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25-Sep UB17 Status 01
25-Sep UB02_03 Phone#
25-Sep UB44_01_03 HCPCS 73630
26-Sep UB47_TOTCHG 7486.50
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26-Sep UB15 Admission SRC 2
26-Sep UB17 Status 01
26-Sep UB02_02_01 Address PO BOX 412026
26-Sep UB44_01_18 HCPCS
26-Sep UB43_01 ServiceDescription Line-1 N400378967193
27-Sep UB74_02 Other Procedure Date B 071824
27-Sep UB67 N Other Diag N M4800
27-Sep UB67 O Other Diag O Z79899
28-Sep UB42_01_03 Revenue Code 0636
28-Sep UB03 A Pat Control Number H9283167302
28-Sep UB76_03 Atten Phy ID Qualifier 0B
30-Sep UB66 DX_Cd_00 0
30-Sep UB67 B Other Diag B I2699
30-Sep UB47_01_05 Line Charge 1350.00
1-Oct UB31 A Occurrence Code 11
1-Oct UB31 A Occurrence Date 032024
1-Oct UB34 A Occurrence Date
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1-Oct UB43_02 NDC Quantity Line-14 1.000
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1-Oct UB59_02 Pat Rel - B
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1-Oct UB45_01_03 Service Date 04092024
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3-Oct UB45_01_14 Service Date 04252024
3-Oct UB46_01_20 Units 1.000
3-Oct UB47_01_20 Line Charge 230.00
3-Oct UB09 03 Patient State NC
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3-Oct UB11 Patient Sex F
3-Oct UB44_01_01 HCPCS 99282
3-Oct UB74 Procedure Code 0CN7XZZ
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3-Oct UB74_04 Other Procedure Code D
3-Oct UB02_02_02 City FAYETTEVILLE
3-Oct UB44_01_15 HCPCS Q5002
3-Oct UB47_01_16 Line Charge 7.20
3-Oct UB42_01_14 Revenue Code 0350
5-Oct UB44_01_02 HCPCS 73110
5-Oct NULL BENSON CHARLOTTE W
10-Oct NULL BEGROW BARBARA
10-Oct UB03 A Pat Control Number 0000029147
10-Oct UB03 B Medical Record Number 14770
10-Oct UB05 Federal TaxID 660939967
10-Oct UB06_01 Statement From Date 050424
10-Oct UB06_02 Statement To Date 050424
10-Oct UB10 Patient DOB 09161992
10-Oct UB61_01 Grp Name - A 90330
12-Oct UB44_01_01 HCPCS 73030
12-Oct UB43_01 ServiceDescription Line-6 LAB HEMATOLOGY
12-Oct UB47_01_22 Line Charge
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14-Oct UB44_01_08 HCPCS 99284
14-Oct UB44M_01_08 Modifier 1 25
14-Oct UB44R_01_08
14-Oct UB44_01_05 HCPCS 90832
14-Oct UB44M_02_05 Modifier 2
14-Oct UB45_01_05 Service Date 060324
14-Oct UB46_01_04 Units 1
14-Oct UB57_01 Provider ID A
14-Oct UB57_02 Provider ID B
15-Oct UB47_TOTCHG 3293.21
16-Oct UB44_01_01 HCPCS 73030
16-Oct NULL GONSETH, JAMIE JO
17-Oct UB15 Admission SRC 2
19-Oct UB69 Adm Diag Code
19-Oct UB46_01_23 Units
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19-Oct UB48 Non Covered Charge_23
21-Oct UB43_01 ServiceDescription Line-23
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21-Oct UB42_01_23 Revenue Code
21-Oct UB44_01_23 HCPCS
21-Oct UB45_01_23 Service Date
22-Oct UB60_01 Insured ID - A 10606927700
22-Oct UB01_03 Phone No
22-Oct NULL 1649234568 KNEBL JANICE
22-Oct UB76_05 Atten Phy Last Name KNEBL
22-Oct UB76_06 Atten Phy First Name JANICE
22-Oct UB77_02 Oper Phy NPI
22-Oct UB78_02 Oth_Phy NPI
22-Oct UB79_02 Oth_Phy NPI
22-Oct UB45_01_23 Service Date
22-Oct UB46_01_23 Units
22-Oct UB47_01_23 Line Charge
22-Oct UB48 Non Covered Charge_23
22-Oct NULL SCHLARBAUM SARAH
23-Oct UB38_02_06 Phone # 8662186020
23-Oct UB57_01 Provider ID A
24-Oct UB42_01_23 Revenue Code
24-Oct UB45_01_23 Service Date
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24-Oct UB48 Non Covered Charge_23
24-Oct UB67 1 Principal Diagnosis POA
24-Oct UB44_01_02 HCPCS 97140
24-Oct UB67 A Other Diag A M25562
25-Oct UB59_02 Pat Rel - B
25-Oct NULL MARCELLO NANCY I
25-Oct UB42_01_02 Revenue Code
25-Oct UB43_01 ServiceDescription Line-2
25-Oct UB44_01_02 HCPCS
25-Oct UB45_01_02 Service Date
25-Oct UB46_01_02 Units
25-Oct UB47_01_02 Line Charge
25-Oct UB48 Non Covered Charge_02
26-Oct UB59_02 Pat Rel - B
26-Oct UB62_02 Grp No - B
26-Oct NULL 1992048110 ELMARSAFI TAMMER
28-Oct UB67 1 Principal Diagnosis S0083XA
28-Oct UB67 A Other Diag A S0990XA
28-Oct UB38_02_05_01 Insured Zip Ext
29-Oct UB47_TOTCHG 2365.41
29-Oct UB70 Pat/Reason DX_A J90
29-Oct UB70 Pat/Reason DX_B Z79899
29-Oct UB70 Pat/Reason DX_C Z452
29-Oct UB09 04 Patient ZipCode 06903
29-Oct UB80 Remarks UB-04CMS-1450
29-Oct UB42_01_23 Revenue Code
29-Oct UB45_01_23 Service Date
29-Oct UB47_01_23 Line Charge
29-Oct UB48 Non Covered Charge_23
29-Oct UB09 04 Patient Zipcode Ext 1616
13-Nov UB01_03 Phone No
13-Nov UB02_02_04 Zipcode 26062
13-Nov UB02_02_05
13-Nov UB50_01_01 Payer Name A UGS MEDICARE
13-Nov UB52_01_01 ROI A Y
13-Nov UB42_01_02 Revenue Code 0300
13-Nov UB44_01_02 HCPCS 84443
13-Nov UB45_01_02 Service Date 01242024
13-Nov UB46_01_02 Units 1
13-Nov UB47_01_02 Line Charge 64.00
13-Nov UB72 ECI Code A Y92239
13-Nov NULL HISSOM, RUSSELL, A
13-Nov UB02_02_04 Zipcode 15264
18-Nov UB44_01_11 HCPCS 87040
18-Nov UB44M_01_11 Modifier 1 59
19-Nov UB42_01_15 Revenue Code 0352
19-Nov UB45_01_15 Service Date 01312024
19-Nov UB46_01_15 Units 3
19-Nov UB47_01_15 Line Charge 7657.00
20-Nov UB09 04 Patient Zipcode Ext
20-Nov NULL VANDENBOSCH, GLORYANNA
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27-Sep 21 Diagnosis Code 5 E119
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27-Sep Diagnosis Code 9
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27-Sep Diagnosis Code 11
30-Sep FACILITY CITY KINGWOOD
30-Sep 3.PATIENT DOB 72174
23-Sep 4. Insured Name BRINKLEY BRANDON DESEAN
25-Sep Diagnosis Code 6 M7918
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18-Nov 12.DATE 110624
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