claimformitemnum | claimformnum | trial_imagefilename_3 | trial_fieldname_4 | formatstring | xpos | ypos | width | height |
|---|---|---|---|---|---|---|---|---|
| 1496 | 7 | P15TreatProvNPI | 701 | 702 | 105 | 14 | ||
| 1495 | 7 | P13TreatProvNPI | 701 | 669 | 105 | 14 | ||
| 1494 | 7 | P12TreatProvNPI | 701 | 652 | 105 | 14 | ||
| 1493 | 7 | P11TreatProvNPI | 701 | 636 | 105 | 14 | ||
| 1492 | 7 | P15Date | * TRIAL | 415 | 703 | 59 | 14 | |
| 1491 | 7 | P2Surface | 63 | 486 | 50 | 14 | ||
| 1490 | 7 | * TRIA | 540 | 486 | 60 | 14 | ||
| 1489 | 7 | * TRIAL * | 63 | 502 | 50 | 14 | ||
| 1488 | 7 | P1Fee | 688 | 468 | 63 | 14 | ||
| 1487 | 7 | P1Date | MM/dd/yy | 415 | 469 | 59 | 14 | |
| 1486 | 7 | * TRIAL * TRI | 142 | 469 | 255 | 14 | ||
| 1485 | 7 | * TRIAL * TRIAL * TRI | 152 | 402 | 131 | 0 | ||
| 1484 | 7 | * TRIAL | 28 | 735 | 565 | 57 | ||
| 1483 | 7 | P1Code | 540 | 469 | 60 | 14 | ||
| 1482 | 7 | P1Surface | 63 | 469 | 50 | 14 | ||
| 1481 | 7 | PayToDentistZip | 345 | 357 | 100 | 14 | ||
| 1480 | 7 | PlaceIsPatientsHome | 71 | 402 | 131 | 0 | ||
| 1479 | 7 | * TRIAL * TRIAL | 38 | 357 | 200 | 14 | ||
| 1478 | 7 | * TRIAL * TRI | 31 | 401 | 0 | 0 | ||
| 1477 | 7 | PayToDentistAddress | 38 | 323 | 245 | 14 | ||
| 1476 | 7 | IsAutoAccident | 394 | 190 | 0 | 0 | ||
| 1475 | 7 | PatientST | 348 | 157 | 100 | 14 | ||
| 1474 | 7 | * TRIAL * TRIA | 244 | 357 | 75 | 14 | ||
| 1473 | 7 | IsOccupational | 395 | 221 | 0 | 0 | ||
| 1472 | 7 | BillingDentist | 38 | 290 | 245 | 14 | ||
| 1471 | 7 | * TRIAL * | 486 | 157 | 100 | 14 | ||
| 1470 | 7 | * TRIAL * TRIAL | 394 | 190 | 0 | 0 | ||
| 1469 | 7 | PatientCity | 38 | 157 | 300 | 14 | ||
| 1468 | 7 | OtherInsExists | 597 | 189 | 0 | 0 | ||
| 1467 | 7 | * TRIAL * TRIAL | 435 | 94 | 0 | 0 | ||
| 1466 | 7 | * TRIAL * TRI | 406 | 94 | 0 | 0 | ||
| 1465 | 7 | PatientLastFirst | 38 | 91 | 225 | 14 | ||
| 1464 | 7 | * TRIA | 688 | 702 | 63 | 14 | ||
| 1463 | 7 | P15ToothNumber | 25 | 703 | 30 | 14 | ||
| 1462 | 7 | P15Description | 142 | 703 | 255 | 14 | ||
| 1461 | 7 | * TRIAL * | 63 | 703 | 50 | 14 | ||
| 1460 | 7 | P13ToothNumber | 25 | 669 | 30 | 14 | ||
| 1459 | 7 | * TRIAL | 540 | 669 | 60 | 14 | ||
| 1458 | 7 | P14Date | MM/dd/yy | 415 | 686 | 59 | 14 | |
| 1457 | 7 | P14Description | 142 | 686 | 255 | 14 | ||
| 1456 | 7 | P12Surface | 63 | 652 | 50 | 14 | ||
| 1455 | 7 | * TRIAL * TRIA | 25 | 653 | 30 | 14 | ||
| 1454 | 7 | P13Description | 142 | 669 | 255 | 14 | ||
| 1453 | 7 | * TRIAL | 540 | 686 | 60 | 14 | ||
| 1452 | 7 | * TRIA | 688 | 669 | 63 | 14 | ||
| 1451 | 7 | * TRIAL * TRIA | 142 | 652 | 255 | 14 | ||
| 1450 | 7 | P12Fee | 688 | 653 | 63 | 14 | ||
| 1449 | 7 | P13Surface | 63 | 669 | 50 | 14 | ||
| 1448 | 7 | * TRIAL | MM/dd/yy | 415 | 669 | 59 | 14 | |
| 1447 | 7 | * TRIAL | 540 | 652 | 60 | 14 | ||
| 1446 | 7 | P12Date | MM/dd/yy | 415 | 652 | 59 | 14 | |
| 1445 | 7 | * TRIAL | * TRIAL | 415 | 636 | 59 | 14 | |
| 1444 | 7 | P3Fee | 688 | 502 | 63 | 14 | ||
| 1443 | 7 | P3Code | 540 | 502 | 60 | 14 | ||
| 1442 | 7 | P3Description | 142 | 502 | 255 | 14 | ||
| 1441 | 7 | P11Description | 142 | 636 | 255 | 14 | ||
| 1440 | 7 | * TRIA | 688 | 636 | 63 | 14 | ||
| 1439 | 7 | P4Surface | 63 | 519 | 50 | 14 | ||
| 1438 | 7 | P3Date | MM/dd/yy | 415 | 502 | 59 | 14 | |
| 1437 | 7 | P2Date | * TRIAL | 415 | 486 | 59 | 14 | |
| 1436 | 7 | * TRI | 688 | 486 | 63 | 14 | ||
| 1435 | 7 | * TRIAL * TRIA | 25 | 686 | 30 | 14 | ||
| 1434 | 7 | * TRIAL * TRI | 142 | 486 | 255 | 14 | ||
| 1433 | 7 | P15Code | 540 | 703 | 60 | 14 | ||
| 1432 | 7 | P14Surface | 63 | 685 | 50 | 14 | ||
| 1431 | 7 | P14Fee | 688 | 686 | 63 | 14 | ||
| 1430 | 7 | * TRIAL * | 63 | 636 | 50 | 14 | ||
| 1429 | 7 | * TRIAL * | 63 | 603 | 50 | 14 | ||
| 1428 | 7 | * TRIAL | 540 | 636 | 60 | 14 | ||
| 1427 | 7 | P9Date | MM/dd/yy | 415 | 603 | 59 | 14 | |
| 1426 | 7 | P9Description | 142 | 603 | 255 | 14 | ||
| 1425 | 7 | * TRI | 688 | 553 | 63 | 14 | ||
| 1424 | 7 | P11ToothNumber | 25 | 636 | 30 | 14 | ||
| 1423 | 7 | P8Fee | 688 | 587 | 63 | 14 | ||
| 1422 | 7 | P8Date | * TRIAL | 415 | 587 | 59 | 14 | |
| 1421 | 7 | P8Description | 142 | 587 | 255 | 14 | ||
| 1420 | 7 | P7Code | 540 | 570 | 60 | 14 | ||
| 1419 | 7 | * TRI | 688 | 570 | 63 | 14 | ||
| 1418 | 7 | * TRIA | 540 | 587 | 60 | 14 | ||
| 1417 | 7 | * TRIAL * | 63 | 570 | 50 | 14 | ||
| 1416 | 7 | P8Surface | 63 | 587 | 50 | 14 | ||
| 1415 | 7 | P7Date | MM/dd/yy | 415 | 570 | 59 | 14 | |
| 1414 | 7 | P7Description | 142 | 570 | 255 | 14 | ||
| 1413 | 7 | P6Description | 142 | 553 | 255 | 14 | ||
| 1412 | 7 | P6Code | 540 | 553 | 60 | 14 | ||
| 1411 | 7 | P6Date | * TRIAL | 415 | 553 | 59 | 14 | |
| 1410 | 7 | * TRI | 688 | 536 | 63 | 14 | ||
| 1409 | 7 | P5Description | 142 | 536 | 255 | 14 | ||
| 1408 | 7 | * TRIAL * | 63 | 553 | 50 | 14 | ||
| 1407 | 7 | P4Code | 540 | 519 | 60 | 14 | ||
| 1406 | 7 | P5Code | 540 | 536 | 60 | 14 | ||
| 1405 | 7 | P5Surface | 63 | 536 | 50 | 14 | ||
| 1404 | 7 | P4Description | 142 | 519 | 255 | 14 | ||
| 1403 | 7 | P8ToothNumOrArea | 25 | 586 | 30 | 14 | ||
| 1402 | 7 | P5Date | MM/dd/yy | 415 | 536 | 59 | 14 | |
| 1401 | 7 | P10ToothNumOrArea | 25 | 619 | 30 | 14 | ||
| 1400 | 7 | P4Fee | 688 | 519 | 63 | 14 | ||
| 1399 | 7 | P4Date | MM/dd/yy | 415 | 519 | 59 | 14 | |
| 1398 | 7 | P3ToothNumOrArea | 25 | 502 | 30 | 14 | ||
| 1397 | 7 | P9ToothNumOrArea | 25 | 603 | 30 | 14 |