Doe, Jordan 50Y, M 01/02/1976 Acct No : 500001

Claim No:	9113000
Claim Date

Bill Type

	Bill To	Name
P		Medicaid

#		Code	Name
1			Encounter for general adult medical examination
2			Encounter for immunization

CPT/Revenue Codes
CPT/HCPCS

#		Code	POS	TOS	SDOS	EDOS	M1	M2	M3	M4	ICD1	ICD2	ICD3	ICD4	Units	Billed Fee	Pro Id
1
2
3
4
*