Denti-Cal-07 Arial 9 false DC-217.gif 0 -5 840 1105 P9Date MM/dd/yy 415 601 59 14 P9Description 140 601 255 14 P9Surface 63 601 50 14 P8Fee 688 584 63 14 P8Code 540 584 60 14 P8Date MM/dd/yy 415 585 59 14 P8Description 140 584 255 14 P8Surface 63 584 50 14 P7Fee 688 567 63 14 P7Code 540 567 60 14 P7Date MM/dd/yy 415 568 59 14 P7Description 140 567 255 14 P7Surface 63 567 50 14 P6Fee 688 550 63 14 P6Code 540 550 60 14 P6Date MM/dd/yy 415 550 59 14 P6Description 140 550 255 14 P6Surface 63 550 50 14 P5Fee 688 533 63 14 P5Code 540 533 60 14 P5Date MM/dd/yy 415 533 59 14 P5Description 140 533 255 14 P5Surface 63 533 50 14 P4Fee 688 517 63 14 P4Code 540 517 60 14 P4Date MM/dd/yy 415 517 59 14 P4Description 140 517 255 14 P4Surface 63 517 50 14 P3Fee 688 500 63 14 P3Code 540 500 60 14 P3Date MM/dd/yy 415 500 59 14 P3Description 140 500 255 14 P3Surface 63 500 50 14 P2Fee 688 484 63 14 P2Code 540 484 60 14 P2Date MM/dd/yy 415 484 59 14 P2Description 140 484 255 14 P2Surface 63 484 50 14 P1Fee 688 466 63 14 P1Code 540 467 60 14 P1Date MM/dd/yy 415 467 59 14 P1Description 140 467 255 14 P1Surface 63 467 50 14 Remarks 33 730 565 57 PlaceIsPatientsHome 71 399 131 0 PlaceIsSkilledNursFac 155 399 131 0 PlaceIsOffice 31 398 0 0 BillingDentistZip 345 355 100 14 BillingDentistST 244 355 75 14 BillingDentistCity 38 355 200 14 BillingDentistAddress 38 321 245 14 BillingDentist 38 288 245 14 IsAutoAccident 395 187 0 0 IsOccupational 395 220 0 0 IsOtherAccident 396 187 0 0 OtherInsExists 599 186 0 0 PatientZip 486 155 100 14 PatientST 348 155 100 14 PatientCity 38 155 300 14 PatientAddress 38 121 500 14 PatientIsFemale 437 90 0 0 PatientLastFirst 38 89 225 14 PatientIsMale 409 90 0 0 RadiographsNumAttached 111 217 30 14 IsRadiographsAttached 186 187 0 0 P9Code 540 601 60 14 P9Fee 688 601 63 14 P10Surface 63 618 50 14 P10Description 140 617 255 14 P10Date MM/dd/yy 415 617 59 14 P10Code 540 617 60 14 P10Fee 688 617 63 14 TotalFee 817 723 90 14 TreatingDentistSignature 41 877 260 14 TreatingDentistSigDate MM/dd/yyyy 324 876 100 14 BillingDentistPh123 300 322 40 14 BillingDentistPh456 348 322 40 14 BillingDentistPh78910 392 322 63 14 TreatingDentistSigDate MM/dd/yyyy 716 836 100 14 PlaceIsInpatHosp 233 399 0 0 PlaceIsOutpatHosp 273 399 0 0 PlaceIsOtherLocation 311 399 0 0 IsOrtho 810 252 0 0 PatientDOB MM dd yy 477 91 115 14 PatientMedicaidID 596 88 130 14 PlaceIsAdultLivCareFac 193 399 0 0 BillingDentistMedicaidID 299 289 137 14 P2TreatDentMedicaidID 701 484 105 14 P1TreatDentMedicaidID 701 467 105 14 P3TreatDentMedicaidID 701 500 105 14 P4TreatDentMedicaidID 701 517 105 14 P5TreatDentMedicaidID 701 533 105 14 P6TreatDentMedicaidID 701 550 105 14 P7TreatDentMedicaidID 701 567 105 14 P8TreatDentMedicaidID 701 584 105 14 P9TreatDentMedicaidID 701 601 105 14 P10TreatDentMedicaidID 701 617 105 14 P1ToothNumOrArea 25 467 30 14 P2ToothNumOrArea 25 484 30 14 P3ToothNumOrArea 25 500 30 14 P4ToothNumOrArea 25 517 30 14 P5ToothNumOrArea 25 533 30 14 P6ToothNumOrArea 25 550 30 14 P7ToothNumOrArea 25 567 30 14 P8ToothNumOrArea 25 584 30 14 P9ToothNumOrArea 25 601 30 14 P10ToothNumOrArea 25 617 30 14