| 9103000 |
| # | Code | Name | ||
|---|---|---|---|---|
| 1 | Encounter for insertion of intrauterine contraceptive device | |||
| 2 | Negative depression screening | |||
| * |
| Name | |
|---|---|
| P |
| # | Code | POS | TOS | SDOS | EDOS | M1 | M2 | M3 | M4 | ICD1 | ICD2 | ICD3 | ICD4 | Units | Billed Fee | Pro Id | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | |||||||||||||||||
| 2 | |||||||||||||||||
| 3 | |||||||||||||||||
| * |
| Bill To | Ins Id | Name | State | Subscriber No | Rel | Insured | Group No | |
|---|---|---|---|---|---|---|---|---|
| P | 1660 | United Health Care | CO | X00000000 | 1 | Doe, Alex |
| Id | CPT | Name | Fee |
|---|