Patient #09975
Date of Birth: 02/08/1971 (48)
Primary Insurance: 1096 - United Health (UH)
Referring Physician: Mark Miller
Date of Service: 07/25/2016 
Provider: Shirley Jones, PT (101)
Case: 12/26/2018 - Revenue Center - 5
Posted: 08/01/2016
Location: BMS Testing ZZX OFFIX (OFFIC)
Date of Injury: 12/26/2018
| CPT Code | Units | Modifier 1 | Modifier 2 | Modifier 3 | Diagnosis Codes | POS Indicator | Insurance Preauthorization |
|---|---|---|---|---|---|---|---|
| L97421, 7197, 7295 | 876 | 356-07122016 | |||||
|
|
L97421, 7197, 7295 | 687 | 356-07122016 |