Provider City / Mailing City / National Provider / Employee / Supervising Provider City / Sender / /
Company
Diagnosis Related Group / Billing Provider First Name C C C / /
Facility
Facility Primary Address C C C DN / Facility City C C C DN / Facility Secondary Address O O O DN / Facility Code C C C DN / Facility Postal Code C C C DN / Hospital Facility Fee Guideline / Facility State Code C C C DN / Facility Country Code C C C DN / /