ADA 2006 Medicaid NPI only Arial 9 true ada2006.gif 11 4 834 1058 RadiographsNumAttached 684 738 27 14 IsPreAuth 208 65 0 0 IsStandardClaim 48 65 0 0 PreAuthString 48 112 200 14 PriInsCarrierName 95 161 320 14 PriInsAddress 95 177 320 14 PriInsAddress2 95 193 320 14 PriInsCity 95 209 150 14 PriInsST 251 209 40 14 OtherInsSubscrLastFirst 48 272 340 14 OtherInsExists 296 245 0 14 OtherInsNotExists 196 243 0 14 OtherInsSubscrDOB MM/dd/yyyy 65 310 100 14 PriInsZip 309 209 100 14 OtherInsSubscrIsMale 186 307 0 14 OtherInsSubscrIsFemale 215 307 0 14 OtherInsSubscrID 263 309 130 14 OtherInsGroupNum 48 342 111 14 OtherInsRelatIsSelf 185 343 0 14 OtherInsRelatIsSpouse 237 344 0 14 OtherInsRelatIsChild 301 344 0 14 OtherInsRelatIsOther 366 343 0 14 OtherInsCarrierName 48 369 360 14 OtherInsAddress 48 385 360 14 OtherInsCity 48 401 170 14 OtherInsST 236 401 40 14 OtherInsZip 297 401 90 14 SubscrID 652 398 120 14 GroupNum 444 240 95 14 EmployerName 574 240 230 14 RelatIsSelf 453 288 0 0 RelatIsSpouse 502 288 0 0 RelatIsChild 561 288 0 0 RelatIsOther 650 288 0 0 IsFTStudent 714 287 0 0 IsPTStudent 766 287 0 0 PatientLastFirst 444 321 350 14 PatientAddress 444 337 350 14 PatientAddress2 444 353 350 14 PatientCity 444 369 140 14 PatientST 598 369 58 14 PatientZip 669 369 110 14 PatientDOB MM/dd/yyyy 444 401 90 14 PatientIsMale 583 399 0 0 PatientIsFemale 610 400 0 0 P1Date MM/dd/yyyy 51 466 96 14 P1Area 154 466 28 14 P1System 182 466 28 14 P1ToothNumber 210 466 116 14 P1Surface 326 466 57 14 P1Code 384 466 56 14 P1Description 441 466 307 14 P1Fee 810 466 60 14 P2Date MM/dd/yyyy 51 482 96 14 P2Area 154 482 28 14 P2System 182 482 28 14 P2ToothNumber 210 482 116 14 P2Surface 326 482 57 14 P2Code 384 483 56 14 P2Description 441 482 307 14 P2Fee 810 482 60 14 P3Date MM/dd/yyyy 51 498 96 14 P3Area 154 498 28 14 P3System 183 498 28 14 P3ToothNumber 211 498 116 14 P3Surface 327 498 57 14 P3Code 385 499 56 14 P3Description 441 498 307 14 P3Fee 810 498 60 14 P4Date MM/dd/yyyy 51 514 96 14 P4Area 154 514 28 14 P4System 183 514 28 14 P4ToothNumber 211 514 116 14 P4Surface 327 514 57 14 P4Code 385 515 56 14 P4Description 441 514 307 14 P4Fee 810 514 60 14 P5Date MM/dd/yyyy 51 531 96 14 P5Area 154 531 28 14 P5System 182 531 28 14 P5ToothNumber 210 531 116 14 P5Surface 326 531 57 14 P5Code 384 531 56 14 P5Description 441 531 307 14 P5Fee 810 531 60 14 P6Date MM/dd/yyyy 51 547 96 14 P6Area 154 547 28 14 P6System 182 547 28 14 P6ToothNumber 210 546 116 14 P6Surface 326 547 57 14 P6Code 384 546 56 14 P6Description 441 546 307 14 P6Fee 810 546 60 14 P7Date MM/dd/yyyy 51 562 96 14 P7Area 154 562 28 14 P7System 182 562 28 14 P7ToothNumber 210 562 116 14 P7Surface 326 562 57 14 P7Code 384 562 56 14 P7Description 441 562 307 14 P7Fee 810 562 60 14 P8Date MM/dd/yyyy 51 578 96 14 P8Area 154 578 28 14 P8System 182 578 28 14 P8ToothNumber 210 578 116 14 P8Surface 326 578 57 14 P8Code 384 578 56 14 P8Description 441 578 307 14 P8Fee 810 578 60 14 P9Date MM/dd/yyyy 51 594 96 14 P9Area 154 594 28 14 P9System 182 594 28 14 P9ToothNumber 210 594 116 14 P9Surface 326 594 57 14 P9Code 384 594 56 14 P9Description 441 594 307 14 P9Fee 810 594 60 14 P10Date MM/dd/yyyy 51 609 96 14 P10Area 154 609 28 14 P10System 182 609 28 14 P10ToothNumber 210 609 116 14 P10Surface 326 610 57 14 P10Code 384 610 56 14 P10Description 441 610 307 14 P10Fee 810 610 60 14 TotalFee 810 658 60 14 Miss1 189 643 0 0 Miss2 208 643 0 0 Miss3 231 643 0 0 Miss4 253 643 0 0 Miss5 276 643 0 0 Miss6 298 643 0 0 Miss7 322 643 0 0 Miss8 344 643 0 0 Miss9 353 643 0 0 Miss10 370 643 0 0 Miss11 393 643 0 0 Miss12 411 643 0 0 Miss13 433 643 0 0 Miss14 456 643 0 0 Miss15 476 643 0 0 Miss16 497 643 0 0 Miss17 497 658 0 0 Miss18 477 658 0 0 Miss19 455 658 0 0 Miss20 434 658 0 0 Miss21 415 658 0 0 Miss22 392 658 0 0 Miss23 368 658 0 0 Miss24 352 658 0 0 Miss25 338 658 0 0 Miss26 318 658 0 0 Miss27 300 658 0 0 Miss28 278 658 0 0 Miss29 254 657 0 0 Miss30 230 657 0 0 Miss31 209 658 0 0 Miss32 190 658 0 0 Remarks 86 674 720 30 PatientRelease 52 772 240 14 PatientReleaseDate MM/dd/yyyy 312 772 110 14 PatientAssignment 56 841 240 14 PatientAssignmentDate MM/dd/yyyy 312 841 110 14 PlaceIsOffice 445 738 0 0 PlaceIsHospADA2002 526 737 0 0 PlaceIsExtCareFacilityADA2002 581 737 0 0 PlaceIsOtherADA2002 616 737 0 0 IsNotOrtho 454 768 0 0 IsOrtho 534 768 0 0 DateOrthoPlaced MM/dd/yyyy 664 769 110 14 MonthsOrthoRemaining 497 805 30 14 IsNotReplacementProsth 538 803 0 0 IsReplacementProsth 571 805 0 0 DatePriorProsthPlaced MM/dd/yyyy 664 800 110 14 IsOccupational 456 839 0 0 IsAutoAccident 600 837 0 0 IsOtherAccident 697 837 0 0 AccidentDate MM/dd/yyyy 583 856 80 14 AccidentST 776 855 35 14 BillingDentist 51 918 350 14 BillingDentistAddress 51 935 350 14 BillingDentistAddress2 51 952 350 14 BillingDentistCity 51 968 165 14 BillingDentistST 229 969 40 14 BillingDentistZip 277 969 110 14 BillingDentistLicenseNum 169 999 100 14 BillingDentistSSNorTIN 305 999 115 14 BillingDentistPh123 111 1020 30 14 BillingDentistPh456 150 1020 30 14 BillingDentistPh78910 186 1020 50 14 TreatingDentistSignature 452 919 245 14 TreatingDentistSigDate MM/dd/yyyy 711 919 100 14 TreatingDentistLicense 712 954 110 14 TreatingDentistAddress 443 983 350 14 TreatingDentistCity 443 999 165 14 TreatingDentistST 617 999 40 14 TreatingDentistZip 664 999 110 14 TreatingDentistPh123 492 1019 30 14 TreatingDentistPh456 529 1019 30 14 TreatingDentistPh78910 565 1019 40 14 TreatingProviderSpecialty 692 968 120 14 TreatingDentistNPI 473 954 130 14 PracticeNPI 43 1000 120 14