From Date
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Displays charge begin service date
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Thru Date
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Displays charge ending service date
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Procedure
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Displays charge procedure description
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Modifiers
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Displays charge modifiers
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Quantity
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Displays charge quantity
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Fee
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Displays the Fee per Quantity
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Charges
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Displays the charge amount (Quantity * Fee)
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Allowed
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Displays the charge allowed amount
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EPSDT
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Indicates if charge is the result of Early Pregnancy Screening and Detection Testing program
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Family Plan
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Indicates if charge is the result of Family Planning program
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Emergency
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Indicates if charge is the result of a Emergency condition
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COB
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Indicates if Coordination of Benefits is in effect for the charge
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Base Units
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Displays the Base Units associated with the ASA Code
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ASA Code
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Displays the ASA Code tied to the procedure
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Physician
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Displays physician/anesthesiologist lookup
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Assistant
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Displays assistant/anesthetist lookup
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File Ins
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Indicates how/if the File Insurance flag is overridden for the procedure
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Location
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Displays location lookup
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Place Svc
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Displays place of service lookup
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Type Svc
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Displays type of service lookup
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Diag1 - Diag 3
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Displays the diagnosis codes, descriptions, and related to indicators of the first three diagnoses on the case.
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