| { |
| "</s_$CHARGES 1>": 57643, |
| "</s_$CHARGES 2>": 57667, |
| "</s_$CHARGES 3>": 57691, |
| "</s_1. INSURED PLAN>": 57799, |
| "</s_1.INSURED PLAN>": 57797, |
| "</s_10. PATIENT'S CONDITION>": 57789, |
| "</s_10a. EMPLOYMENT>": 57791, |
| "</s_10b. AUTO ACCIDENT>": 57793, |
| "</s_10c. OTHER ACCIDENT>": 57795, |
| "</s_11. INSURED'S POLICY GROUP OR FECA NUMBER>": 57787, |
| "</s_11a. INSURED'S SEX>": 57785, |
| "</s_11c. INSURANCE PLAN NAME>": 57783, |
| "</s_11d. IS THERE ANOTHER HEALTH BENEFIT PLAN>": 57781, |
| "</s_12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE>": 57779, |
| "</s_13. INSURED OR AUTHORIZED PERSON'S SIGNATURE>": 57777, |
| "</s_17>": 57801, |
| "</s_1a. INSURED'S I.D. NUMBER>": 57775, |
| "</s_2. PATIENT'S NAME>": 57773, |
| "</s_20. LAB $CHARGES>": 57727, |
| "</s_20. OUTSIDE LAB>": 57725, |
| "</s_21. DIAGNOSIS OR NATURE OF ILLNESS>": 57697, |
| "</s_22. RESUBMISSION CODE>": 57695, |
| "</s_23. PRIOR AUTHORIZATION NUMBER>": 57693, |
| "</s_24. SERVICES>": 57619, |
| "</s_25. FEDERAL IDENTIFICATION>": 57617, |
| "</s_25. FEDERAL TAX I.D. NUMBER>": 57615, |
| "</s_26. PATIENT'S ACCOUNT NUMBER>": 57613, |
| "</s_27. ACCEPT ASSIGNMENT>": 57611, |
| "</s_28. TOTAL CHARGE>": 57609, |
| "</s_29. AMOUNT PAID>": 57607, |
| "</s_3. PATIENT'S DATE OF BIRTH>": 57765, |
| "</s_3. PATIENT'S SEX>": 57763, |
| "</s_31. PHYSICIAN OR SUPPLIER SIGNATURE>": 57601, |
| "</s_32. SERVICE FACILITY LOCATION>": 57597, |
| "</s_32. SERVICE INFORMATION>": 57595, |
| "</s_32. a. NPI NUMBER>": 57599, |
| "</s_33. BILLING INFORMATION>": 57587, |
| "</s_33. BILLING PROVIDER LOCATION>": 57591, |
| "</s_33. BILLING PROVIDER PHONE>": 57589, |
| "</s_33. a. NPI NUMBER>": 57593, |
| "</s_4. INSURED'S NAME>": 57739, |
| "</s_5. PATIENT'S ADDRESS>": 57761, |
| "</s_5. PATIENT'S CITY>": 57759, |
| "</s_5. PATIENT'S STATE>": 57757, |
| "</s_5. PATIENT'S TELEPHONE>": 57755, |
| "</s_5. PATIENT'S ZIP CODE>": 57753, |
| "</s_6. PATIENT RELATIONSHIP>": 57751, |
| "</s_7. INSURED'S ADDRESS>": 57741, |
| "</s_7. INSURED'S CITY>": 57745, |
| "</s_7. INSURED'S INFO>": 57737, |
| "</s_7. INSURED'S STATE>": 57743, |
| "</s_7. INSURED'S TELEPHONE>": 57749, |
| "</s_7. INSURED'S ZIP CODE>": 57747, |
| "</s_9. OTHER INSURED'S NAME>": 57735, |
| "</s_9a. OTHER INSURED'S POLICY OR GROUP>": 57733, |
| "</s_9d. INSURANCE PLAN NAME>": 57731, |
| "</s_CPT/HCPCS 1>": 57641, |
| "</s_CPT/HCPCS 2>": 57665, |
| "</s_CPT/HCPCS 3>": 57689, |
| "</s_DATE>": 57605, |
| "</s_DD 1>": 57639, |
| "</s_DD 2>": 57663, |
| "</s_DD 3>": 57687, |
| "</s_DD>": 57771, |
| "</s_DIAGNOSIS POINTER 1>": 57637, |
| "</s_DIAGNOSIS POINTER 2>": 57661, |
| "</s_DIAGNOSIS POINTER 3>": 57685, |
| "</s_EMG 1>": 57635, |
| "</s_EMG 2>": 57659, |
| "</s_EMG 3>": 57683, |
| "</s_Family Plan 1>": 57633, |
| "</s_Family Plan 2>": 57657, |
| "</s_Family Plan 3>": 57681, |
| "</s_ILLNESS A.>": 57719, |
| "</s_ILLNESS B.>": 57717, |
| "</s_ILLNESS C.>": 57715, |
| "</s_ILLNESS D.>": 57713, |
| "</s_ILLNESS E.>": 57723, |
| "</s_ILLNESS F.>": 57721, |
| "</s_MM 1>": 57631, |
| "</s_MM 2>": 57655, |
| "</s_MM 3>": 57679, |
| "</s_MM>": 57769, |
| "</s_MODIFIER 1>": 57629, |
| "</s_MODIFIER 2>": 57653, |
| "</s_MODIFIER 3>": 57677, |
| "</s_PATIENT AND INSURED INFORMATION>": 57729, |
| "</s_PHYSICIAN OR MEDICAL PROVIDER INFORMATION>": 57585, |
| "</s_PLACE OF SERVICE 1>": 57627, |
| "</s_PLACE OF SERVICE 2>": 57651, |
| "</s_PLACE OF SERVICE 3>": 57675, |
| "</s_PROVIDER ID 1>": 57625, |
| "</s_PROVIDER ID 2>": 57649, |
| "</s_PROVIDER ID 3>": 57673, |
| "</s_SIGNED>": 57603, |
| "</s_UNITS 1>": 57623, |
| "</s_UNITS 2>": 57647, |
| "</s_UNITS 3>": 57671, |
| "</s_YY 1>": 57621, |
| "</s_YY 2>": 57645, |
| "</s_YY 3>": 57669, |
| "</s_YY>": 57767, |
| "</s_cashprice>": 57549, |
| "</s_changeprice>": 57551, |
| "</s_cnt>": 57529, |
| "</s_creditcardprice>": 57563, |
| "</s_discount_price>": 57557, |
| "</s_discountprice>": 57567, |
| "</s_emoneyprice>": 57569, |
| "</s_etc>": 57541, |
| "</s_formtype>": 57583, |
| "</s_itemsubtotal>": 57577, |
| "</s_label>": 57711, |
| "</s_menu>": 57525, |
| "</s_menuqty_cnt>": 57555, |
| "</s_menutype_cnt>": 57553, |
| "</s_meta>": 57581, |
| "</s_nm>": 57527, |
| "</s_normalizedVertices>": 57703, |
| "</s_num>": 57565, |
| "</s_othersvc_price>": 57573, |
| "</s_price>": 57531, |
| "</s_service_price>": 57537, |
| "</s_sub>": 57547, |
| "</s_sub_total>": 57533, |
| "</s_subtotal_price>": 57535, |
| "</s_tax_price>": 57539, |
| "</s_text>": 57709, |
| "</s_total>": 57543, |
| "</s_total_etc>": 57561, |
| "</s_total_price>": 57545, |
| "</s_unitprice>": 57559, |
| "</s_vatyn>": 57575, |
| "</s_void_menu>": 57571, |
| "</s_word>": 57701, |
| "</s_words>": 57699, |
| "</s_x>": 57707, |
| "</s_y>": 57705, |
| "<s_$CHARGES 1>": 57642, |
| "<s_$CHARGES 2>": 57666, |
| "<s_$CHARGES 3>": 57690, |
| "<s_1. INSURED PLAN>": 57798, |
| "<s_1.INSURED PLAN>": 57796, |
| "<s_10. PATIENT'S CONDITION>": 57788, |
| "<s_10a. EMPLOYMENT>": 57790, |
| "<s_10b. AUTO ACCIDENT>": 57792, |
| "<s_10c. OTHER ACCIDENT>": 57794, |
| "<s_11. INSURED'S POLICY GROUP OR FECA NUMBER>": 57786, |
| "<s_11a. INSURED'S SEX>": 57784, |
| "<s_11c. INSURANCE PLAN NAME>": 57782, |
| "<s_11d. IS THERE ANOTHER HEALTH BENEFIT PLAN>": 57780, |
| "<s_12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE>": 57778, |
| "<s_13. INSURED OR AUTHORIZED PERSON'S SIGNATURE>": 57776, |
| "<s_17>": 57800, |
| "<s_1a. INSURED'S I.D. NUMBER>": 57774, |
| "<s_2. PATIENT'S NAME>": 57772, |
| "<s_20. LAB $CHARGES>": 57726, |
| "<s_20. OUTSIDE LAB>": 57724, |
| "<s_21. DIAGNOSIS OR NATURE OF ILLNESS>": 57696, |
| "<s_22. RESUBMISSION CODE>": 57694, |
| "<s_23. PRIOR AUTHORIZATION NUMBER>": 57692, |
| "<s_24. SERVICES>": 57618, |
| "<s_25. FEDERAL IDENTIFICATION>": 57616, |
| "<s_25. FEDERAL TAX I.D. NUMBER>": 57614, |
| "<s_26. PATIENT'S ACCOUNT NUMBER>": 57612, |
| "<s_27. ACCEPT ASSIGNMENT>": 57610, |
| "<s_28. TOTAL CHARGE>": 57608, |
| "<s_29. AMOUNT PAID>": 57606, |
| "<s_3. PATIENT'S DATE OF BIRTH>": 57764, |
| "<s_3. PATIENT'S SEX>": 57762, |
| "<s_31. PHYSICIAN OR SUPPLIER SIGNATURE>": 57600, |
| "<s_32. SERVICE FACILITY LOCATION>": 57596, |
| "<s_32. SERVICE INFORMATION>": 57594, |
| "<s_32. a. NPI NUMBER>": 57598, |
| "<s_33. BILLING INFORMATION>": 57586, |
| "<s_33. BILLING PROVIDER LOCATION>": 57590, |
| "<s_33. BILLING PROVIDER PHONE>": 57588, |
| "<s_33. a. NPI NUMBER>": 57592, |
| "<s_4. INSURED'S NAME>": 57738, |
| "<s_5. PATIENT'S ADDRESS>": 57760, |
| "<s_5. PATIENT'S CITY>": 57758, |
| "<s_5. PATIENT'S STATE>": 57756, |
| "<s_5. PATIENT'S TELEPHONE>": 57754, |
| "<s_5. PATIENT'S ZIP CODE>": 57752, |
| "<s_6. PATIENT RELATIONSHIP>": 57750, |
| "<s_7. INSURED'S ADDRESS>": 57740, |
| "<s_7. INSURED'S CITY>": 57744, |
| "<s_7. INSURED'S INFO>": 57736, |
| "<s_7. INSURED'S STATE>": 57742, |
| "<s_7. INSURED'S TELEPHONE>": 57748, |
| "<s_7. INSURED'S ZIP CODE>": 57746, |
| "<s_9. OTHER INSURED'S NAME>": 57734, |
| "<s_9a. OTHER INSURED'S POLICY OR GROUP>": 57732, |
| "<s_9d. INSURANCE PLAN NAME>": 57730, |
| "<s_CPT/HCPCS 1>": 57640, |
| "<s_CPT/HCPCS 2>": 57664, |
| "<s_CPT/HCPCS 3>": 57688, |
| "<s_DATE>": 57604, |
| "<s_DD 1>": 57638, |
| "<s_DD 2>": 57662, |
| "<s_DD 3>": 57686, |
| "<s_DD>": 57770, |
| "<s_DIAGNOSIS POINTER 1>": 57636, |
| "<s_DIAGNOSIS POINTER 2>": 57660, |
| "<s_DIAGNOSIS POINTER 3>": 57684, |
| "<s_EMG 1>": 57634, |
| "<s_EMG 2>": 57658, |
| "<s_EMG 3>": 57682, |
| "<s_Family Plan 1>": 57632, |
| "<s_Family Plan 2>": 57656, |
| "<s_Family Plan 3>": 57680, |
| "<s_ILLNESS A.>": 57718, |
| "<s_ILLNESS B.>": 57716, |
| "<s_ILLNESS C.>": 57714, |
| "<s_ILLNESS D.>": 57712, |
| "<s_ILLNESS E.>": 57722, |
| "<s_ILLNESS F.>": 57720, |
| "<s_MM 1>": 57630, |
| "<s_MM 2>": 57654, |
| "<s_MM 3>": 57678, |
| "<s_MM>": 57768, |
| "<s_MODIFIER 1>": 57628, |
| "<s_MODIFIER 2>": 57652, |
| "<s_MODIFIER 3>": 57676, |
| "<s_PATIENT AND INSURED INFORMATION>": 57728, |
| "<s_PHYSICIAN OR MEDICAL PROVIDER INFORMATION>": 57584, |
| "<s_PLACE OF SERVICE 1>": 57626, |
| "<s_PLACE OF SERVICE 2>": 57650, |
| "<s_PLACE OF SERVICE 3>": 57674, |
| "<s_PROVIDER ID 1>": 57624, |
| "<s_PROVIDER ID 2>": 57648, |
| "<s_PROVIDER ID 3>": 57672, |
| "<s_SIGNED>": 57602, |
| "<s_UNITS 1>": 57622, |
| "<s_UNITS 2>": 57646, |
| "<s_UNITS 3>": 57670, |
| "<s_YY 1>": 57620, |
| "<s_YY 2>": 57644, |
| "<s_YY 3>": 57668, |
| "<s_YY>": 57766, |
| "<s_cashprice>": 57550, |
| "<s_changeprice>": 57552, |
| "<s_cnt>": 57530, |
| "<s_cord-v2>": 57579, |
| "<s_creditcardprice>": 57564, |
| "<s_discount_price>": 57558, |
| "<s_discountprice>": 57568, |
| "<s_emoneyprice>": 57570, |
| "<s_etc>": 57542, |
| "<s_formtype>": 57582, |
| "<s_iitcdip>": 57523, |
| "<s_itemsubtotal>": 57578, |
| "<s_label>": 57710, |
| "<s_menu>": 57526, |
| "<s_menuqty_cnt>": 57556, |
| "<s_menutype_cnt>": 57554, |
| "<s_meta>": 57580, |
| "<s_nm>": 57528, |
| "<s_normalizedVertices>": 57702, |
| "<s_num>": 57566, |
| "<s_othersvc_price>": 57574, |
| "<s_price>": 57532, |
| "<s_service_price>": 57538, |
| "<s_sub>": 57548, |
| "<s_sub_total>": 57534, |
| "<s_subtotal_price>": 57536, |
| "<s_synthdog>": 57524, |
| "<s_tax_price>": 57540, |
| "<s_text>": 57708, |
| "<s_total>": 57544, |
| "<s_total_etc>": 57562, |
| "<s_total_price>": 57546, |
| "<s_unitprice>": 57560, |
| "<s_vatyn>": 57576, |
| "<s_void_menu>": 57572, |
| "<s_word>": 57700, |
| "<s_words>": 57698, |
| "<s_x>": 57706, |
| "<s_y>": 57704, |
| "<sep/>": 57522 |
| } |
|
|