| Pos |
Segment |
M/C |
Repeat |
Repr. |
Notes |
| 010 |
|
7402 |
Object identifier |
M |
4 |
an..35 |
|
| 020 |
|
E507 |
DATE/TIME/PERIOD |
C |
5 |
|
|
|
|
2005 |
Date or time or period function code qualifier |
M |
|
an..3 |
|
|
|
2380 |
Date or time or period value |
C |
|
an..35 |
|
|
|
2379 |
Date or time or period format code |
C |
|
an..3 |
|
| 030 |
|
E021 |
SERVICE |
C |
1 |
|
|
|
|
7135 |
Product identifier |
M |
|
an..35 |
|
|
|
1131 |
Code list identification code |
C |
|
an..17 |
|
|
|
9629 |
Procedure modification code |
C |
|
an..3 |
|
|
|
9629 |
Procedure modification code |
C |
|
an..3 |
|
|
|
9629 |
Procedure modification code |
C |
|
an..3 |
|
|
|
9629 |
Procedure modification code |
C |
|
an..3 |
|
| 040 |
|
6060 |
Quantity |
C |
2 |
an..35 |
|
| 050 |
|
5004 |
Monetary amount |
C |
5 |
n..35 |
|
| 060 |
|
5030 |
Index text |
C |
4 |
an..35 |
|
| 070 |
|
9039 |
Facility type description code |
C |
1 |
an..3 |
|
| 080 |
|
5267 |
Service type code |
C |
1 |
an..3 |
|
| 090 |
|
4183 |
Special condition code |
C |
9 |
an..3 |
|
| 100 |
|
E024 |
SUPPORTING EVIDENCE |
C |
1 |
|
|
|
|
9643 |
Supporting evidence type code qualifier |
M |
|
an..3 |
|
|
|
1154 |
Reference identifier |
M |
|
an..70 |
|
|
|
3153 |
Communication medium type code |
C |
|
an..3 |
|