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{"sheet":"Front","index":0,"n_rows":72,"n_cols":29,"rows_kept":72,"merged":[[23,2,26,6],[60,2,60,4]],"flags":["formulas_cached_only"]}
["Family PACT   SAMPLE",{"$nulls":9},"   WHEN CUSTOMIZING INCLUDE ONLY LABS, DRUGS, & SERVICES PROVIDED ONSITE"]
["Client Name:_______________________________",{"$nulls":12},"DOB: ________________________",{"$nulls":7},"Service Date: __________________"]
["Telephone: ________________________________",{"$nulls":12},"Alt. Contact: __________________",{"$nulls":7},"M.R. #  _______________________"]
["HAP #: ___________________________________",{"$nulls":12},"Exp. Date: ____________________",{"$nulls":7},"Return: _______________________"]
[]
["Office Visit",{"$nulls":6},"Primary Diagnosis -- S-Code Required for Every Claim",{"$nulls":13},"     Procedure"]
["New Client E & M ",{"$nulls":6},"S-Code",{"$nulls":7},"Labs by S-Code",{"$nulls":3},"       ",null,"Procedure",null,null,"Use Surgical Modifier -AG"]
[null,null,"99201",null,null,"10 min M/F ",{"$nulls":3},"S101","OC, patch, ring eval/initiate",{"$nulls":4},"1(a)(c),  2(c), 7, 8, 9(d),",{"$nulls":5},"Note:  NMPs use surgical modifer + specialty modifier"]
[null,null,"99202",null,null,"20 min M/F ",{"$nulls":3},"S102","OC, patch, ring maint",{"$nulls":4},"10(b)(d), 16",{"$nulls":6},"11975",null,"Implant insertion"]
[null,null,"99203",null,null,"30 min M/F ",{"$nulls":3},"S103","Complication/TAR ",{"$nulls":11},"11976 ",null,"Implant removal"]
[null,null,"99204",null,null,"45 min F",{"$nulls":3},"S201","Injection eval/initiate",{"$nulls":4},"2(c), 7, 9(d), 10(b)(d), 16",{"$nulls":6},"11977",null,"Implant removal/reinsertion"]
["Established Client E & M",{"$nulls":8},"S202","Injection maintain",{"$nulls":11},"55250 ",null,"Vasectomy"]
[null,null,"99211",null,null," 5  min M/F",{"$nulls":3},"S203","Complication/TAR ",{"$nulls":11},"58565",null,"Essure procedure "]
[null,null,"99212",null,null,"10 min M/F",{"$nulls":3},"S301","Implant eval/initiate",{"$nulls":4},"2(c), 7, 16",{"$nulls":6},"57170 ",null,"Diaphragm fitting"]
[null,null,"99213",null,null,"15 min M/F",{"$nulls":3},"S302","Implant maintain",{"$nulls":11},"58300 ",null,"Insert IUC"]
[null,null,"99214",null,null,"25 min F",{"$nulls":3},"S303","Complication/TAR ",{"$nulls":11},"58301 ",null,"Remove IUC"]
["Education & Counseling",{"$nulls":8},"S401","IUC eval/initiate",{"$nulls":4},"7, 11, 12, 13, 16",{"$nulls":6},"58600 ",null,"Mini Lap TL"]
[null,null,"Z9750",null,null,"Group M/F (or) w ",{"$nulls":3},"S402","IUC maintain",{"$nulls":11},"58615 ",null,"Mini Lap TL with clip"]
[null,null,"Z9751",null,null,"Indiv 10 min M/F w",{"$nulls":3},"S403","Complication/TAR ",{"$nulls":11},"58670",null,"Lapscope fulguration"]
[null,null,"w One time only codes",{"$nulls":6},"S501","Barrier eval/initiate",{"$nulls":4},"7, 16",{"$nulls":6},"58671 ",null,"Lapscope w/ ring or clip"]
[null,null,"Z9752",null,null,"15 min M/F †",{"$nulls":4},"   FAM, NFP, LAM",{"$nulls":10},"Surgical Supply Tray"]
[null,null,"Z9753",null,null,"30 min M/F †",{"$nulls":3},"S502","Barrier maintain",{"$nulls":11},"11976 ZM        ",{"$nulls":3},"Implant removal supplies"]
[null,null,"Z9754",null,null,"45 min M/F †",{"$nulls":4},"   FAM, NFP, LAM",{"$nulls":11},"55250 ZM/ZN          ",{"$nulls":3},"Vasectomy supplies"]
[null,null," † No more than one per day and two visits, in any combination, in rolling 30 days. See PPBI for details.",{"$nulls":6},"S503","Complication/TAR ",{"$nulls":11},"58300 ZM",{"$nulls":3},"IUC insertion supplies"]
[{"$nulls":9},"S601","Preg test ONLY",{"$nulls":4},"7 only",{"$nulls":6},"58301 ZM",{"$nulls":3},"IUC removal supplies"]
[{"$nulls":9},"S602","Preg confirmation",{"$nulls":11},"58565 ZM/ZN",{"$nulls":3},"Essure supplies"]
[{"$nulls":9},"S701","F sterilization eval/Initiate",{"$nulls":4},"2(c), 3(e), 4(e), 5(e), 6(e), ",{"$nulls":6},"58600 ZM/ZN",{"$nulls":3},"Mini Lap TL supplies"]
["Note:  E&C codes reflect total",{"$nulls":8},"S702","F sterilization surgery",{"$nulls":4},"7, 11(e), 12(e), 13(e), 14(e),",{"$nulls":6},"58615 ZM/ZN",{"$nulls":3},"Mini Lap w/clip supplies"]
["face-to-face time and may be",{"$nulls":8},"S703","Complication/TAR ",{"$nulls":4},"15(e), 16, 17, 18(e), 19(e)",{"$nulls":6},"58670 ZM/ZN",{"$nulls":3},"Lap fulguration supplies"]
["used by all trained staff",{"$nulls":8},"S801","Vasectomy eval",{"$nulls":4},"3(e), 4(e), 5(e), 6(e),",{"$nulls":6},"58671 ZM/ZN",{"$nulls":3},"Lap w/ring or clip supplies"]
[{"$nulls":9},"S802","Vasectomy surgery",{"$nulls":4},"11(e), 12(e), 13(e), 14(e), ",{"$nulls":5},"Use modifier ZM for local or ZN for general anesthesia supplies "]
[{"$nulls":9},"S803","Complication/TAR ",{"$nulls":4},"15(e), 17",{"$nulls":5},"Screening Mammogram Referral"]
[{"$nulls":10},"(a) Only if elevated cholesterol or cardiovascular risk",{"$nulls":12},"(Females ages 40-55; once/year)"]
[{"$nulls":10},"(b) Only if history of abnormal fasting blood screen",{"$nulls":11},"77057",null,"Mammogram, film, bilat (or)"]
[{"$nulls":10},"(c)  Limited to one every six months per client",{"$nulls":11},"G0202",null,"Mammogram, digital, bilat"]
[{"$nulls":10},"(d)  Limited to one per year per client",{"$nulls":11},"77052",null,"Computer Aided Detection"]
[{"$nulls":10},"(e) Pre-operative testing only",{"$nulls":10},"Drugs/Contraceptive Supplies/Devices"]
["Labs:  Screening Tests (All S-Codes except S60)",{"$nulls":10},"Labs - Specific to S-Code Diagnosis ",{"$nulls":10},"58565 ",null,"Essure device (modifier -50 or -52)"]
["Use for symptomatic or asymptomatic clients as ",{"$nulls":12},"1.","80061",null,"Lipid profile",{"$nulls":5},"J7307",null,"Implanon"]
["clinically indicated based on individual assessment",{"$nulls":12},"2.","80076",null,"LFTs",{"$nulls":5},"X1500",null,"Condoms"]
[null,null,"86592",null,null,"VDRL, RPR",{"$nulls":7},"3.","81000",null,"UA dipstick w/micro",{"$nulls":4},"  ","X1500",null,"Spermicide"]
[null,null,"86701",null,null,"HIV - I",{"$nulls":7},"3."," 81000",null,"UA dipstick w/micro",{"$nulls":5},"X1500",null,"Lubricant"]
[null,null,"86701",null,null,"HIV-I ",{"$nulls":7},"4","81001",null,"UA auto w/micro",{"$nulls":5},"X1500",null,"Basal Body Thermometer"]
[null,null,"86702",null,null,"HIV-II",{"$nulls":7},"5. ","81002",null,"UA dipstick w/o micro",{"$nulls":5},"X1500",null,"Diaphragm"]
[null,null,"86703",null,null,"HIV-I & HIV-II single assay",{"$nulls":7},"6.","81003",null,"UA auto w/o micro",{"$nulls":5},"X1500",null,"Lea's Shield or FemCap"]
[null,null,"87081",null,null,"GC culture",{"$nulls":7},"7.","81025",null,"Urine preg test",{"$nulls":5},"X1500",null,"Lubricant"]
[null,null,"87491",null,null,"Chlamydia NAAT",{"$nulls":7},"8.","82465",null,"Cholesterol",{"$nulls":5},"X6051",null,"DMPA"]
[null,null,"87591",null,null,"GC  NAAT",{"$nulls":7},"9.","82947",null,"Glucose",{"$nulls":5},"X7706",null,"OCs "]
[null,null,"87800",null,null,"Inf agent antigen detection  (direct probe)",{"$nulls":7},"10.","82951",null,"2hr GTT",{"$nulls":5},"X7728",null,"Patch"]
[{"$nulls":13},"11.","85013",null,"Hematocrit, spun",{"$nulls":5},"X7730",null,"Ring "]
["LABS:  Screening Tests -- Reflex Tests",{"$nulls":12},"12. ","85014",null,"Hematocrit",{"$nulls":5},"X7722",null,"Plan B (max 2 pkts/visit & 6 pkts/yr)"]
["Based on a positive Screening Test above",{"$nulls":12},"13. ","85018",null,"Hemoglobin",{"$nulls":5},"X1522",null,"ParaGard"]
["     ",null,"(All S-codes except S60)",{"$nulls":10},"14.","85025",null,"CBC w/diff",{"$nulls":5},"X1532",null,"Mirena IUS"]
[null,null,"86781",null,null,"TP-conf test; if positive, 86593 is req'd",{"$nulls":7},"15.","85027",null,"CBC w/o diff",{"$nulls":5},"Z7610*",null,"Estradiol"]
[null,null,"86593",null,null,"Syphilis test, quantitative",{"$nulls":7},"Cytology Orders for lab:",{"$nulls":7},"* See reverse for additional use of Z7610"]
[null,null,"86689",null,null,"HIV confirmation",{"$nulls":7},"16.","88142-3",null,"Pap",{"$nulls":4},"Biller:  Itemize dose, quantity, cost, & disp fee"]
[null,null,"87490",null,null,"Chlamydia direct probe",{"$nulls":8},"88147-8",null,"Pap ",{"$nulls":4},"of Drugs/Supplies in REMARKS on claim"]
[null,null,"87590",null,null,"GC direct probe",{"$nulls":8},"88164-5",null,"Pap ",{"$nulls":4},"Complication Management (TAR Req'd)"]
[{"$nulls":14},"88167",null,"Pap ",{"$nulls":4},"Complication",{"$nulls":3}," S____3__   Description:     "]
["BLOOD DRAW & HANDLING",{"$nulls":13},"88174-5",null,"Pap "]
[null,null,"99000",{"$nulls":3},"Blood specimen handling and/or",{"$nulls":5},"See Cervical Abn for reflex tests and HPV test",{"$nulls":8},"Secondary Dx"]
[{"$nulls":6},"conveyance to unaffiliated lab",{"$nulls":6},"17.","88302",null,"Surgical pathology",{"$nulls":4},"Procedure/Code(s):"]
[{"$nulls":13},"18.","93000",null,"ECG  "]
[{"$nulls":13},"19.","71020",null,"Chest X-ray",{"$nulls":4},"Supplies/Code(s):"]
["By signing below, I agree that I have received the services listed on this form including products/prescriptions, drugs/devices given onsite or by written"]
["order, and/or that I have given a specimen for the performance of a laboratory test or examination."]
[]
["Date:  ________________  ",{"$nulls":6},"Signature:  ______________________________________      Print name:  ______________________________"]
[]
[]
["Date:  ________________",{"$nulls":6},"Clinician Signature: _________________________________________________________"]
[{"$nulls":28},"                    1/23/09v_rev"]

{"sheet":"Back","index":1,"n_rows":70,"n_cols":39,"rows_kept":70,"merged":[[0,12,0,41],[1,2,1,39]],"flags":["formulas_cached_only"]}
[null,null,"Family PACT",{"$nulls":9},"SECONDARY RELATED REPRODUCTIVE HEALTH CONDITIONS"]
[null,null,"Primary Diagnosis S-Code Required for Every Claim; Secondary Diagnosis ICD-9-CM Code Required to Test or Treat"]
["Chlamydia  ",{"$nulls":13},"Syphilis   ",{"$nulls":12}," Urinary Tract Infections (Females Only)"]
[null,null,"099.41",null,null,"Ct, urethritis",{"$nulls":10},"091.0  ",null,null,"Primary",{"$nulls":9},"595.0",null,"Acute cystitis"]
[null,null,"099.52",null,null,"Ct, anus, rectum",{"$nulls":10},"091.3",null,null,"Secondary",{"$nulls":9},"599.71",null,"Gross hematuria"]
[null,null,"099.53",null,null,"Ct, lower GU, cervix ",{"$nulls":10},"092.9",null,null,"Early latent",{"$nulls":9},"788.1",null,"Dysuria"]
[null,null,"099.40 (M)",null,null,"NGU/NSU ",{"$nulls":10},"096",null,null,"Late latent",{"$nulls":9},"788.41",null,"Urinary frequency"]
[null,null,"604.90 (M)",null,null,"Acute epididymitis/orchitis",{"$nulls":10},"097.1",null,null,"Latent, unspecified",{"$nulls":9},"789.09",null,"Abdominal pain,bilateral"]
[null,null,"616.0 (F)",null,null,"Cervicitis",{"$nulls":10},"616.50 (F)  ",null,null,"Vulvar ulcer",{"$nulls":7},"Labs  ",null,null,"For symptomatic females only"]
[null,null,"V01.6 (M/F)   ",null,null,"Ct exposed partner",{"$nulls":10},"608.89 (M)  ",null,null,"Penile ulcer",{"$nulls":9},"81000",null,"Urinalysis, dipstick w/micro"]
["Labs   (For Screening Tests, see S-Codes)",{"$nulls":15},"V01.6 (M/F)  ",null,null,"Syphilis exposed partner",{"$nulls":9},"81001",null,"Urinalysis, automated w/micro"]
[null,null,"87205  ","Gram Stain (Males only)",{"$nulls":10},"Labs  ",null,null,"(For Screening Tests, see S-Codes)",{"$nulls":11},"81002",null,"Urinalysis dipstick w/o micro"]
["Drugs   Quantity:_________________",{"$nulls":15},"Limited to ICD-9s 091.0, 091.3, 092.9, 096, 097.1:",{"$nulls":12},"81003",null,"Urinalysis, automated w/o micro"]
[null,null,"X7716   ","Azithromycin 250mg tabs",{"$nulls":12},"86593  ",null,"Syphilis, quantitative",{"$nulls":10},"81005",null,"Urinalysis, qualitative"]
[null,null,"Z7610* ","Azithromycin 500mg tabs/1gm pkt",{"$nulls":10},"Drugs   ",null,null,"Quantity:_________________",{"$nulls":11},"81015",null,"Urine microscopy"]
[null,null,"Z7610*  ","Doxycyline  100mg tabs",{"$nulls":12},"X7460",null,"Benzathine PCN 1.2m units/cc",{"$nulls":10},"87086",null,"Urine culture"]
["For alternative regimens, see Grid",{"$nulls":15},"X7462",null,"Benzathine PCN 2.4m units/cc",{"$nulls":10},"87181",null,"Susceptibility studies; agar (reflex only)"]
[{"$nulls":14},"For alternative regimens, see Grid",{"$nulls":14},"87184",null,"Susceptibility studies; disk (reflex only)"]
[{"$nulls":29},"87186",null,"Susceptibility studies, microdilution, or agar (reflex)"]
["Gonorrhea    ",{"$nulls":13},"Trichomoniasis   ",{"$nulls":12},"Drugs   Quantity:_________________"]
[null,null,"098.0",null,null,"Urethritis",{"$nulls":10},"131.01",null,"Trichomonal vulvovaginitis",{"$nulls":10},"Z7610*",null,"Cephalexin 250/500mg tabs"]
[null,null,"098.12",null,null,"Prostatitis",{"$nulls":10},"131.02",null,"(M/F) Trichomonal urethritis",{"$nulls":10},"Z7610*",null,"Ciprofloxacin 250/500mg tabs; 500mg SR tabs"]
[null,null,"098.15",null,null,"Gonococcal cervicitis (acute)",{"$nulls":10},"099.40 (M) NGU/NSU",{"$nulls":12},"Z7610*",null,"Nitrofurantoin 100mg/100mg SR tabs"]
[null,null,"098.6",null,null,"GC, pharynx",{"$nulls":10},"V01.6",null,"(M/F) Trichomoniasis exposed partner",{"$nulls":10},"Z7610*",null,"TMP/SMX 80/400mg tabs"]
[null,null,"098.7",null,null,"GC, anus/rectum",{"$nulls":8},"Labs  ",null,null,"Quantity:_________________",{"$nulls":11},"Z7610*",null,"TMP/SMX DS 160/800mg tabs"]
[null,null,"099.40 (M)",null,null,"NGU/NSU",{"$nulls":10},"83986",null,"pH (Females only)"]
[null,null,"616.0 (F)",null,null,"Cervicitis",{"$nulls":10},"Q0111 Wet mount (provider performed)",{"$nulls":10},"Cervical Abnormalities (Females aged 15-55)"]
[null,null,"V01.6 (M,F)",null,null,"GC exposed partner",{"$nulls":10},"87210",null,"Wet mount (sent to lab)",{"$nulls":10},"795.01",null,"ASC-US Pap"]
["Labs  (For Screening Tests, see S-Codes) ",{"$nulls":13},"Drugs  Quantity:_________________",{"$nulls":14},"795.02",null,"ASC-H Pap"]
[null,null,"87205         ","Gram stain (males only)",{"$nulls":12},"Z7610*",null,"Metronidazole 500mg tabs",{"$nulls":10},"795.03",null,"LSIL Pap"]
["Drugs  Quantity:_________________",{"$nulls":13},"For alternative regimens, see Grid",{"$nulls":14},"795.04",null,"HSIL Pap"]
[null,null,"Z7610","Cefixime 400mg tab",{"$nulls":25},"795.05",null,"Abn Pap w/HPV high risk positive"]
[null,null,"X5864   ","Ceftriaxone 250 mg IM",{"$nulls":10},"Vulvovaginitis",{"$nulls":14},"622.2",null,"Leukoplakia, cervix"]
["For alternative regimens, see Grid",{"$nulls":15},"112.1",null,"Candidal vulvovaginitis",{"$nulls":8},"Procedures",{"$nulls":3},"Use Surgical, NMP, and Supplies modifiers"]
[{"$nulls":16},"616.10",null,"Vaginitis/vulvitis/BV",{"$nulls":10},"57452 ",null,"Colposcopy"]
["Herpes, Genital  ",{"$nulls":13},"Labs ",{"$nulls":14},"57454 ",null,"Colpo w/biopsy & ECC"]
[null,null,"054.11",null,"HSV vulvovaginitis",{"$nulls":11},"83986 ",null,"pH (females only)",{"$nulls":10},"57455",null,"Colpo w/biopsy"]
[null,null,"054.12",null,"Herpes vulva",{"$nulls":11},"Q0111",null,"Wet mount (provider performed)",{"$nulls":10},"57456",null,"Colpo w/ECC"]
[null,null,"054.13",null,"Herpes penis",{"$nulls":11},"87210",null,"Wet mount (sent to lab)",{"$nulls":8},"Labs  "]
[null,null,"608.89 (M)  ",null,"Penile ulcer",{"$nulls":9},"Drugs  ",null,null,"Quantity:_________________",{"$nulls":11},"87621",null,"HPV DNA amplified probe, high risk; ages ≥21"]
[null,null,"616.50 (F)   ",null,"Vulvar ulcer",{"$nulls":11},"Vaginal candidiasis:",{"$nulls":14},"Do not bill 87621 with  795.04 or 622.2"]
["Labs  Limited to ICD-9s 608.89 and 616.50:",{"$nulls":15},"Z7610*",null,"Butoconazole 2%SR cream",{"$nulls":10},"88305",null,"Surgical pathology"]
[null,null,"87252  ","HSV culture",{"$nulls":12},"Z7610*",null,"Clotrimazole 1%/2%crm; 100/200mg vag tabs",{"$nulls":10},"795.00   ",null,"AGC Pap"]
[null,null,"87255","HSV culture",{"$nulls":12},"Z7610*",null,"Fluconazole 150mg tab",{"$nulls":8},"Procedures",{"$nulls":3},"Use Surgical, NMP, and Supplies modifiers"]
[null,null,"87273  ","HSV DFA, type 2",{"$nulls":12},"Z7610*",null,"Miconazole 2%/4%crm; 100/200mg vag supp",{"$nulls":10},"57452 ",null,"Colposcopy"]
["Drugs  Quantity:_________________",{"$nulls":15},"Z7610*",null,"Terconazole  0.4%/0.8%crm; 80mg supp",{"$nulls":10},"57454 ",null,"Colpo w/biopsy & ECC"]
[null,null,"Z7610* Acyclovir 200/400/800mg",{"$nulls":13},"Bacterial vaginosis:",{"$nulls":12},"57455 ",null,"Colpo w/biopsy"]
[{"$nulls":16},"Z7610*",null,"Metronidazole 250/500mg tabs; 0.75% vag gel",{"$nulls":10},"57456 ",null,"Colpo w/ECC"]
["PID (Females)  ",{"$nulls":15},"Z7610*",null,"Clindamycin 2% crm",{"$nulls":10},"58110",null,"Endometrial biopsy + Colpo"]
[null,null,"614.0  ","PID ",{"$nulls":10},"For alternative regimens, see Grid",{"$nulls":12},"Labs  "]
[null,null,"614.2","PID, NOS",{"$nulls":25},"87621",null,"HPV DNA amplified probe, high risk; ages ≥21"]
[null,null,"615.0","Acute myometritis",{"$nulls":10},"Warts, Genital Only ",{"$nulls":14},"88305",null,"Surgical Pathology"]
["Labs  ",{"$nulls":15},"078.0      ",null,"Molluscum",{"$nulls":10},"622.11",null,"CIN 1",null,null,"  622.12 CIN 2",{"$nulls":3}," 233.1  CIN 3"]
[null,null,"85025","CBC/diff",{"$nulls":12},"078.10   ",null,"Viral warts",{"$nulls":8},"Procedures  ",{"$nulls":3},"Use Surgical, NMP, and Supplies modifiers"]
[null,null,"85651","ESR (sed rate), non-auto",{"$nulls":12},"078.11   ",null,"Condylomata",{"$nulls":10},"57452 ",null,"Colposcopy"]
[null,null,"85652","ESR (sed rate), auto",{"$nulls":10},"Procedures",{"$nulls":3},"Use Surgical and Supplies modifiers",{"$nulls":10},"57454 ",null,"Colpo w/biopsy & ECC"]
["Drugs  Quantity:_________________",{"$nulls":15},"54050  ",null,"Chem destr, penile lesion",{"$nulls":10},"57455 ",null,"Colpo w/biopsy"]
[null,null,"X5854   ","Cefoxitin 1gm/2gm IM",{"$nulls":12},"54056 ",null,"Cryo destr, penile lesion",{"$nulls":10},"57456 ",null,"Colpo w/ECC"]
[null,null,"X5864   ","Ceftriaxone 250mg IM",{"$nulls":12},"54100  ",null,"Biopsy, penis",{"$nulls":10},"57460 ",null,"LEEP"]
[null,null,"Z7610*  ","Doxycycline 100mg tabs",{"$nulls":12},"56501 ",null,"Destruction vulvar lesion",{"$nulls":10},"57511",null,"Cryocautery of cervix"]
[null,null,"Z7610*  ","Probenecid 500mg tabs",{"$nulls":12},"57061",null,"Destruction vaginal lesion",{"$nulls":8},"Labs  "]
["For alternative regimens, see Grid",{"$nulls":15},"56605 ",null,"Biopsy, vulva",{"$nulls":10},"87621",null,"HPV DNA amplified probe, high risk; ages ≥21"]
[{"$nulls":14},"Labs  ",{"$nulls":14},"88305",null,"Surgical pathology"]
[{"$nulls":16},"88304  ",null,"Surgical pathology",{"$nulls":10},"88307",null,"Surgical pathology, LEEP only"]
[{"$nulls":14},"Drugs  ",null,null,"Quantity:_________________",{"$nulls":11},"795.09",null,"Other Abnormal Pap"]
[{"$nulls":16},"Z7610*",null,"Imiquimod 5% cream ",{"$nulls":8},"Procedures",{"$nulls":3},"Use Surgical, NMP, and Supplies modifiers"]
[{"$nulls":16},"Z7610*",null,"Podofilox 0.5% solution/gel",{"$nulls":10},"58100",null,"Endometrial biopsy (Ages 40-55)"]
[{"$nulls":27},"Labs  "]
[{"$nulls":29},"88305",null,"Surgical pathology"]
["*Onsite dispensing of Miscellaneous Drugs (Z7610) is restricted to hospital outpatient departments, emergency rooms, surgical clinics, and community clinics.                   1/23/09v"]