SUBMITTERNAME SUBMITTERADDR1 SUBMITTERCITY SUBMITTERST SUBMITTERZIP SUBMITTERCONTACT SUBMITTERID BILLINGPROVIDERNAME BILLINGPROVIDERADDR1 BILLINGPROVIDERADDR2 BILLINGPROVIDERCITY BILLINGPROVIDERST BILLINGPROVIDERZIP BILLINGPROVIDERIDTYPE BILLINGPROVIDERIDCODE BILLINGPROVIDERID SUBLNAME SUBFNAME SUBMI SUBIDCODE SUBADDR1 SUBADDR2 SUBCITY SUBST SUBZIP SUBSEX SUBSTATUS SUBDOB SUBREL SUBORDER PATLNAME PATFNAME PATMI PATADDR1 PATADDR2 PATCITY PATST PATZIP PATSEX PATMSTAT PATDOB PATREL PAYERNAME PAYERADDR1 PAYERADDR2 PAYERCITY PAYERST PAYERZIP CLAIMID CLAIMAMT POSCODE ICNDCN FACILITYNAME FACILITYADDR1 FACILITYADDR2 FACILITYCITY FACILITYST FACILITYZIP FACILITYIDTYPE FACILITYIDCODE FACILITYID FACILITYSECONDARYIDTYPE FACILITYSECONDARYIDCODE FACILITYSECONDARYID OTHERDXA1 OTHERDXA2 OTHERDXA3 OTHERDXA4 OTHERDXA5 OTHERDXB1 OTHERDXB2 OTHERDXB3 OTHERDXB4 OTHERDXB5 OTHERDXC1 OTHERDXC2 OTHERDXC3 OTHERDXC4 OTHERDXC5 OTHERDXD1 OTHERDXD2 OTHERDXD3 OTHERDXD4 OTHERDXD5 OTHERDXE1 OTHERDXE2 OTHERDXE3 OTHERDXE4 OTHERDXE5 OTHERDXF1 OTHERDXF2 OTHERDXF3 OTHERDXF4 OTHERDXF5 OTHERDXG1 OTHERDXG2 OTHERDXG3 OTHERDXG4 OTHERDXG5 OTHERDXH1 OTHERDXH2 OTHERDXH3 OTHERDXH4 OTHERDXH5 OTHERDXI1 OTHERDXI2 OTHERDXI3 OTHERDXI4 OTHERDXI5 OTHERDXJ1 OTHERDXJ2 OTHERDXJ3 OTHERDXJ4 OTHERDXJ5 IREVCODE1 IPROCTYPE1 IPROC1 IMODA1 IMODB1 IMODC1 IDOS1 IAMT1 IUNITS1 IPRICEAMT1 IPRICEREF1 IADJUDID1 IADJUDAMT1 IADJUDDATE1 IREVCODE2 IPROCTYPE2 IPROC2 IMODA2 IMODB2 IMODC2 IDOS2 IAMT2 IUNITS2 IPRICEAMT2 IPRICEREF2 IADJUDID2 IADJUDAMT2 IADJUDDATE2 IREVCODE3 IPROCTYPE3 IPROC3 IMODA3 IMODB3 IMODC3 IDOS3 IAMT3 IUNITS3 IPRICEAMT3 IPRICEREF3 IADJUDID3 IADJUDAMT3 IADJUDDATE3 IREVCODE4 IPROCTYPE4 IPROC4 IMODA4 IMODB4 IMODC4 IDOS4 IAMT4 IUNITS4 IPRICEAMT4 IPRICEREF4 IADJUDID4 IADJUDAMT4 IADJUDDATE4 IREVCODE5 IPROCTYPE5 IPROC5 IMODA5 IMODB5 IMODC5 IDOS5 IAMT5 IUNITS5 IPRICEAMT5 IPRICEREF5 IADJUDID5 IADJUDAMT5 IADJUDDATE5 IREVCODE6 IPROCTYPE6 IPROC6 IMODA6 IMODB6 IMODC6 IDOS6 IAMT6 IUNITS6 IPRICEAMT6 IPRICEREF6 IADJUDID6 IADJUDAMT6 IADJUDDATE6 IREVCODE7 IPROCTYPE7 IPROC7 IMODA7 IMODB7 IMODC7 IDOS7 IAMT7 IUNITS7 IPRICEAMT7 IPRICEREF7 IADJUDID7 IADJUDAMT7 IADJUDDATE7 IREVCODE8 IPROCTYPE8 IPROC8 IMODA8 IMODB8 IMODC8 IDOS8 IAMT8 IUNITS8 IPRICEAMT8 IPRICEREF8 IADJUDID8 IADJUDAMT8 IADJUDDATE8 IREVCODE9 IPROCTYPE9 IPROC9 IMODA9 IMODB9 IMODC9 IDOS9 IAMT9 IUNITS9 IPRICEAMT9 IPRICEREF9 IADJUDID9 IADJUDAMT9 IADJUDDATE9 IREVCODE10 IPROCTYPE10 IPROC10 IMODA10 IMODB10 IMODC10 IDOS10 IAMT10 IUNITS10 IPRICEAMT10 IPRICEREF10 IADJUDID10 IADJUDAMT10 IADJUDDATE10