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October 22, 2022

DIAGNOSIS DAYS EPSOT OR RENDERING MM DD YY MM DO YY GERNICE EMG CPTHCPCS MODIFIER POINTER $ CHARGES LIMITS PROVIDER 10 Ihealyou, DO 05 05 19 05 05 19 11 99214 1,2,3 175.00 NPI 9876543210 NPI NPI NPI NPI NPI

DATES) OF SERVICE L. D. PROCEDURES, SERVICES, OR SUPPLIES G H. From To PLACE OF (Explain Unusual Circumstances)] DIAGNOSIS DAYS EPSOT OR RENDERING MM DD YY MM DO YY GERNICE EMG CPTHCPCS MODIFIER POINTER $ CHARGES LIMITS PROVIDER 10 Ihealyou, DO 05 05 19 05 05 19 11 99214 1,2,3 175.00 NPI 9876543210 NPI NPI NPI NPI NPI

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