| 5000000 |
| Tth No | Srfc | Description of Service Performed | DOS | Proc No | ICD1 | ICD2 | ICD3 | ICD4 | Units | Fee | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | PERIODIC ORAL EVALUATION | ||||||||||||
| 2 | DENTAL CONSULT | ||||||||||||
| Code | Name | ||
|---|---|---|---|
| 1 | Encounter for dental exam | ||
| Bill To | Ins Id | Name | State | Subscriber No | Rel | Insured | Group No | |
|---|---|---|---|---|---|---|---|---|
| P | 1001 | DentaQuest | CO | X000000 | Self | TESTPATIENT, Demo |