interface/billing/ub04_form.php

   1 <?php
   2 /**
   3  * UB04 Claims Form
   4  *
   5  * @package   OpenEMR
   6  * @link      http://www.open-emr.org
   7  * @author    Jerry Padgett <sjpadgett@gmail.com>
   8  * @author    Brady Miller <brady.g.miller@gmail.com>
   9  * @copyright Copyright (c) 2017 Jerry Padgett <sjpadgett@gmail.com>
  10  * @copyright Copyright (c) 2019 Brady Miller <brady.g.miller@gmail.com>
  11  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  12  */
  13 /* $isAuthorized tells us if the form is for user UI or claim processing and provides another security check */
  14 if ($isAuthorized !== true) {
  15     require_once("./ub04_dispose.php");
  16     $isAuthorized = 0;
  17     $pid = $_REQUEST['pid'] ? $_REQUEST['pid'] : '0';
  18     $encounter = $_REQUEST['enc'] ? $_REQUEST['enc'] : '0';
  19     $action = $_REQUEST['action'] ? $_REQUEST['action'] : false;
  20     $payerid = $_REQUEST['id'] ? $_REQUEST['id'] : '0';
  21     $imgurl = $GLOBALS['images_static_relative'];
  22     if ($action == 'payer_defaults') {
  23         $ub04id = get_payer_defaults($payerid);
  24     } elseif ($pid && $encounter) {
  25         $ub04id = json_encode(get_ub04_array($pid, $encounter));
  26     } else {
  27         exit(xlt("Sorry! Not Authorized."));
  28     }
  29 } else {
  30     $imgurl = "../../../../public/images";
  31 }
  32
  33 ?>
  34 <!DOCTYPE html >
  35 <html>
  36 <head>
  37 <meta http-equiv="X-UA-Compatible" content="IE=Edge" />
  38 <meta charset="utf-8" />
  39 <?php if ($isAuthorized !== true) {?>
  40 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery/dist/jquery.min.js"></script>
  41 <script type="text/javascript" src="<?php echo $webroot ?>/interface/main/tabs/js/include_opener.js?v=<?php echo $v_js_includes; ?>"></script>
  42  <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/bootstrap/dist/css/bootstrap.min.css">
  43  <link href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-ui-themes/themes/base/jquery-ui.min.css" rel="stylesheet" type="text/css" />
  44 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker/build/jquery.datetimepicker.min.css">
  45 <script src="<?php echo $GLOBALS['assets_static_relative']; ?>/bootstrap/dist/js/bootstrap.min.js" type="text/javascript"></script>
  46 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/emodal/dist/eModal.min.js"></script>
  47 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker/build/jquery.datetimepicker.full.min.js"></script>
  48 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative'] ?>/jquery-ui/jquery-ui.min.js"></script>
  49
  50 <script type="text/javascript">
  51 $(function() {
  52     $( "[title*='DATE']" ).datetimepicker({
  53         <?php $datetimepicker_timepicker = false; ?>
  54         <?php $datetimepicker_showseconds = false; ?>
  55         <?php $datetimepicker_formatInput = false; ?>
  56         <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
  57         <?php echo(",validateOnBlur: false, formatDate: 'mdy', format: 'mdy'") ?>
  58     });
  59
  60     $(".user").on( 'dblclick', function( event ) {
  61         event.preventDefault();
  62         selectUser(this.id,event);
  63     });
  64     $("#dismissHelp").click(function(e){
  65         e.preventDefault();
  66         $('#formHelp').toggle();
  67     });
  68
  69     $( function() {
  70         var cache = {};
  71         $( "[title*='REVENUE CODE']" ).autocomplete({
  72           minLength: 1,
  73           source: function( request, response ) {
  74             var term = request.term;
  75             request.code_group = "revenue_code";
  76             if ( term in cache ) {
  77               response( cache[ term ] );
  78               return;
  79             }
  80             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
  81               cache[ term ] = data;
  82               response( data );
  83             });
  84           }
  85         }).dblclick(function(event) {
  86             $(this).autocomplete('search'," ");
  87         });
  88       });
  89     $( function() {
  90         var cache = {};
  91         $( "[title*='OCCURRENCE CODE']" ).autocomplete({
  92             minLength: 1,
  93             source: function( request, response ) {
  94               var term = request.term;
  95               request.code_group = "occurrence_code";
  96               if ( term in cache ) {
  97                 response( cache[ term ] );
  98                 return;
  99               }
 100               $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 101                 cache[ term ] = data;
 102                 response( data );
 103               });
 104             }
 105           }).dblclick(function(event) {
 106               $(this).autocomplete('search'," ");
 107           });
 108     });
 109     $( function() {
 110         var cache = {};
 111         $( "[title*='OCCURRENCE SPAN CODE']" ).autocomplete({
 112             minLength: 1,
 113             source: function( request, response ) {
 114               var term = request.term;
 115               request.code_group = "occurrence_span_code";
 116               if ( term in cache ) {
 117                 response( cache[ term ] );
 118                 return;
 119               }
 120               $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 121                 cache[ term ] = data;
 122                 response( data );
 123               });
 124             }
 125           }).dblclick(function(event) {
 126               $(this).autocomplete('search'," ");
 127           });
 128     });
 129     $( function() {
 130         var cache = {};
 131         $( "[title*='VALUE CODE']" ).autocomplete({
 132           minLength: 1,
 133           source: function( request, response ) {
 134             var term = request.term;
 135             request.code_group = "value_codes";
 136             if ( term in cache ) {
 137               response( cache[ term ] );
 138               return;
 139             }
 140             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 141               cache[ term ] = data;
 142               response( data );
 143             });
 144           }
 145         }).dblclick(function(event) {
 146             $(this).autocomplete('search'," ");
 147         });
 148       });
 149     $( function() {
 150         var cache = {};
 151         $( "[title*='CONDITION CODE']" ).autocomplete({
 152           minLength: 1,
 153           source: function( request, response ) {
 154             var term = request.term;
 155             request.code_group = "condition_code";
 156             if ( term in cache ) {
 157               response( cache[ term ] );
 158               return;
 159             }
 160             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 161               cache[ term ] = data;
 162               response( data );
 163             });
 164           }
 165         }).dblclick(function(event) {
 166             $(this).autocomplete('search'," ");
 167         });
 168       });
 169     $( function() {
 170         var cache = {};
 171         $( "[title*='STATUS']" ).autocomplete({
 172           minLength: 1,
 173           source: function( request, response ) {
 174             var term = request.term;
 175             request.code_group = "patient_status_code";
 176             if ( term in cache ) {
 177               response( cache[ term ] );
 178               return;
 179             }
 180             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 181               cache[ term ] = data;
 182               response( data );
 183             });
 184           }
 185         }).dblclick(function(event) {
 186             $(this).autocomplete('search'," ");
 187         });
 188       });
 189
 190     $('form :input').change(function(e){
 191            formChanged = true;
 192            $(this).css("color","red");
 193            return false;
 194     });
 195 });
 196 <?php } else {?>
 197 <script type="text/javascript">
 198 <?php } ?>
 199 var pid;
 200 var encounter;
 201 var align = true;
 202 var isTemplate;
 203 var ub04id = new Array();
 204 payerid = <?php echo js_escape($payerid);?>;
 205 pid = <?php echo js_escape($pid);?>;
 206 encounter = <?php echo js_escape($encounter);?>;
 207 isTemplate = <?php echo js_escape(($isAuthorized === true ? $isAuthorized : 0)); ?>;
 208 ub04id = <?php echo js_escape($ub04id);?>;
 209
 210 function adjustForm()
 211 {
 212     // cycle trough the input fields
 213     // rem form index i is not same as formid index ii
 214     var inputs = Array.prototype.slice.call(document.forms[0])
 215
 216     Array.prototype.forEach.call(inputs, function(el, i) {
 217         var type = el.getAttribute('type');
 218         var ta = window.getComputedStyle(el,null).getPropertyValue("text-align");
 219         var title = el.getAttribute('title')
 220         var max = el.getAttribute('maxlength');
 221         var w = el.clientWidth
 222         var size = w;
 223             if( ta == 'right' ){
 224                 if(title.indexOf("CHARGES") !== -1){
 225                      w = size - 14;
 226                      if(!isTemplate){ w = size - 8; }
 227                 }
 228                 else{
 229                     w = size - 8;
 230                     if(!isTemplate){ w = size - 4; }
 231                 }
 232                 el.style.width = w + 'px'
 233             }
 234         el.style.top = (el.offsetTop+3)+'px'
 235         if( ta == 'left' )
 236             el.style.left = (el.offsetLeft+2)+'px'
 237         var ii = i+1;
 238         if(typeof(ub04id[ii]) != 'undefined' && ub04id[ii] != ""){
 239             var val = ub04id[ii]
 240             if( val.length > max && max > 0 ){
 241                 val = ub04id[ii].substring(0,max);
 242             }
 243             document.getElementById("ub04id"+ ii.toString()).value = val
 244             return;
 245         }
 246  });
 247  return false;
 248 }
 249 <?php if ($isAuthorized !== true) {?>
 250 var formChanged = false;
 251
 252 function rewrite(ub04id){
 253     var inputs = Array.prototype.slice.call(document.forms[0])
 254     Array.prototype.forEach.call(inputs, function(el, i) {
 255         var max = el.getAttribute('maxlength');
 256         var ii = i+1;
 257         if(typeof(ub04id[ii]) != 'undefined'){
 258             var val = ub04id[ii]
 259             if( val.length > max && max > 0 ){
 260                 val = ub04id[ii].substring(0,max);
 261             }
 262             document.getElementById("ub04id"+ ii.toString()).value = val
 263             return;
 264         }
 265     });
 266 }
 267
 268 function cleanUp()
 269 {
 270     if(payerid == '0'){
 271        window.opener.SubmitTheScreen();
 272     }
 273     window.close()
 274 }
 275
 276 function selectUser(formid,event)
 277 {
 278     var title = 'Providers';
 279      var params = {
 280                buttons: [
 281                    { text: 'Cancel', close: true, style: 'default btn-sm'} ],
 282                //size: eModal.size.sm,
 283                subtitle: 'Provider Info.',
 284                title: title,
 285                useBin: false,
 286                url: './ub04_helpers.php?action=user_select&formid=' + encodeURIComponent(formid)
 287            };
 288        return eModal.ajax(params)
 289            .then(function () { });
 290 }
 291
 292 function updateProvider(formid, selected)
 293 {
 294     document.getElementById(formid).value = selected.npi;
 295     if(formid == 'ub04id379'){
 296         document.getElementById('ub04id388').value = selected.lname;
 297         document.getElementById('ub04id389').value = selected.fname;
 298         document.getElementById('ub04id289').value = selected.taxonomy;
 299     }
 300     else if(formid == 'ub04id390'){
 301         document.getElementById('ub04id400').value = selected.lname;
 302         document.getElementById('ub04id401').value = selected.fname;
 303         document.getElementById('ub04id296').value = selected.taxonomy;
 304     }
 305     else if(formid == 'ub04id406'){
 306         document.getElementById('ub04id413').value = selected.lname;
 307         document.getElementById('ub04id414').value = selected.fname;
 308         document.getElementById('ub04id303').value = selected.taxonomy;
 309     }
 310     else if(formid == 'ub04id420'){
 311         document.getElementById('ub04id427').value = selected.lname;
 312         document.getElementById('ub04id428').value = selected.fname;
 313     }
 314     return false;
 315 }
 316 function disposeSave(action)
 317 {
 318     var htmlout = "";
 319     var inputs;
 320     var slice = Array.prototype.slice;
 321     inputs = slice.call(document.forms[0])
 322     Array.prototype.forEach.call(inputs, function(el, i) {
 323         var ii = i+1;
 324         var tmp = document.getElementById("ub04id"+ ii.toString()).value;
 325         if(tmp){
 326             ub04id[ii] = document.getElementById("ub04id"+ ii.toString()).value.toUpperCase();
 327         }
 328     });
 329     ub04idSave = JSON.stringify(ub04id);
 330     var qstr = param({ handler: 'edit_save',pid:pid,encounter:encounter,action:action,ub04id:ub04idSave });
 331     location.href='ub04_dispose.php?'+qstr;
 332 }
 333
 334 function postClaim(action)
 335 {
 336     var inputs;
 337     var c = [];
 338     var slice = Array.prototype.slice;
 339     inputs = slice.call(document.forms[0])
 340     Array.prototype.forEach.call(inputs, function(el, i) {
 341         var ii = i+1;
 342         var tmp = document.getElementById("ub04id"+ ii.toString()).value;
 343         if(tmp){
 344             var row = el.offsetTop.toString();
 345             var col = el.offsetLeft.toString();
 346             var max = el.getAttribute('maxlength');
 347             var ta = window.getComputedStyle(el,null).getPropertyValue("text-align");
 348             var w = window.getComputedStyle(el,null).getPropertyValue("width");
 349             var ob = {fld:ii,top:row,left:col,max:max,align:ta,width:w}
 350             c.push(ob)
 351             ub04id[ii] = document.getElementById("ub04id"+ ii.toString()).value.toUpperCase();
 352         }
 353     });
 354     var cj = JSON.stringify(c)
 355     ub04idSave = JSON.stringify(ub04id);
 356     var xhr = new XMLHttpRequest();
 357     xhr.open('POST', 'ub04_dispose.php');
 358     xhr.setRequestHeader("Content-Type", "application/x-www-form-urlencoded");
 359     xhr.onload = function() {
 360         if (xhr.status === 200) {
 361             console.log(this.responseText ? this.responseText : 'no response');
 362             if(this.responseText == 'done')
 363                 alert(<?php echo xlj("Save Completed")?>);
 364         }
 365     };
 366     if(action == 'payer_save'){
 367         var qs = param({handler:action,payerid:payerid,ub04id: ub04idSave})
 368     }
 369     else if(action == 'batch_save'){
 370         var qs = param({handler:action,pid:pid,encounter:encounter,ub04id:ub04idSave,loc:cj})
 371     }
 372     xhr.send(qs);
 373 }
 374
 375 function param(object)
 376 {
 377     var encodedString = '';
 378     for (var prop in object) {
 379         if (object.hasOwnProperty(prop)) {
 380             if (encodedString.length > 0) {
 381                 encodedString += '&';
 382             }
 383             encodedString += encodeURI(prop + '=' + object[prop]);
 384         }
 385     }
 386     return encodedString;
 387 }
 388
 389 var scale = 1.25;
 390 function myZoom()
 391 {
 392     var el = document.getElementById('p1');
 393     scale += 0.05;
 394     if(scale > 1.25) scale = 1.0;
 395     el.style.transform = 'scale(' + scale + ')';
 396 }
 397
 398 function resetClaim(){
 399     var msg = <?php echo xlj('This action will reset your claim!'); ?> + '\n' + <?php echo xlj('Click OK if you are sure.'); ?>;
 400     var yn = confirm(msg);
 401     if (yn != true) {
 402         return false;
 403     }
 404     $.ajax({
 405         type: 'GET',
 406         url: 'ub04_dispose.php',
 407         data: {handler:'reset_claim',pid:pid,encounter:encounter},
 408         dataType: 'json',
 409         success: function( rtn ) {
 410           ub04id = rtn;
 411           document.getElementById('ub04Data').reset();
 412           rewrite(ub04id);
 413         }
 414     });
 415 }
 416
 417 <?php } ?>
 418 </script>
 419
 420 <style>
 421 .container {
 422 text-align:center;
 423 }
 424
 425 .ui-autocomplete {max-height: 250px; max-width: 25%; width: 50%; overflow-y: auto; overflow-x: hidden;}
 426
 427 input{
 428     z-index:2;
 429     text-transform: uppercase;
 430     position: absolute; border-width:0px;
 431     height:14px; color: rgb(0,0,0);
 432     background: transparent; border-color:transparent;
 433     font:normal 10pt 'Times New Roman', Times, serif;
 434 }
 435
 436 textarea{
 437     z-index:2;
 438     text-transform: uppercase;
 439     position: absolute; border-width:0px;
 440     color: rgb(0,0,0);
 441     background: transparent; border-color:transparent;
 442     font:normal 10pt 'Times New Roman', Times, serif;
 443 }
 444
 445 input:focus{color: blue !important;}
 446
 447 body {
 448     padding: 0px;
 449     margin-top: 35px;
 450     margin-bottom: 35px;
 451     background-color: lightgrey;
 452 }
 453
 454 #p1 {
 455     transform: scale(1.2);
 456     transform-origin: top center;
 457     margin-top: 0px;
 458     margin-left: auto;
 459     margin-right: auto;
 460 }
 461
 462 #menu {
 463     text-align: center;
 464     z-index: 9999;
 465     background-color: ghostwhite;
 466     position: fixed;
 467     padding:5px 5px 5px 5px;
 468     margin-left: auto;
 469     margin-right: auto;
 470     /* opacity: 0.8; */
 471     top: 0px;
 472 }
 473
 474 @media print {
 475 .datepicker{
 476     border-color:transparent !important;
 477     background-color:transparent !important;
 478 }
 479 .user{
 480     background-color:transparent !important;
 481     border-color:transparent !important;
 482 }
 483 body {
 484     padding: 0px;
 485     margin: 0px;
 486     background-color: #fff;
 487 }
 488 .formhide {
 489     display: none;
 490 }
 491 #p1 {
 492     margin-top: 0px;
 493     margin-left: 0px;
 494     margin-right: 0px;
 495 }
 496 input{
 497     z-index:2;
 498     text-transform: uppercase;
 499     position: absolute; border-width:0px;
 500     height:14px; color: rgb(0,0,0);
 501     background: transparent; border-color:transparent;
 502     font:normal 10pt 'Times New Roman', Times, serif;
 503 }
 504 textarea{
 505     z-index:2;
 506     text-transform: uppercase;
 507     position: absolute; border-width:0px;
 508     color: rgb(0,0,0);
 509     background: transparent; border-color:transparent;
 510     font:normal 10pt 'Times New Roman', Times, serif;
 511 }
 512 }
 513
 514 #ub04id1{ left:301px; top:19px; width:264px;  text-align:left;}
 515 #ub04id2{ left:26px;  top:19px; width:264px;  text-align:left;}
 516 #ub04id3{ left:599px; top:19px; width:263px;  text-align:left;}
 517 #ub04id4{ left:26px;  top:37px; width:264px;  text-align:left;}
 518 #ub04id5{ left:301px; top:37px; width:264px;  text-align:left;}
 519 #ub04id6{ left:599px; top:37px; width:263px;  text-align:left;}
 520 #ub04id7{ left:862px; top:37px; width:57px;  text-align:center;}
 521 #ub04id8{ left:26px;  top:57px; width:264px;  text-align:left;}
 522 #ub04id9{ left:301px; top:57px; width:264px;  text-align:left;}
 523 #ub04id10{left:26px;  top:74px; width:264px;  text-align:left;}
 524 #ub04id11{left:301px; top:74px; width:264px;  text-align:left;}
 525 #ub04id12{left:567px; top:74px; width:110px;  text-align:left;}
 526 #ub04id13{left:675px; top:74px; width:77px;  text-align:center;}
 527 #ub04id14{left:753px; top:74px; width:77px;  text-align:center;}
 528 #ub04id15{resize:none; left:842px; top:55px; width:77px; height:32px; color: rgb(0,0,0); text-align:left;}
 529 #ub04id16{left:138px; top:92px; width:208px;  text-align:left;}
 530 #ub04id17{left:468px; top:92px; width:451px;  text-align:left;}
 531 #ub04id18{left:28px;  top:110px; width:318px;  text-align:left;}
 532 #ub04id19{left:358px; top:110px; width:352px;  text-align:left;}
 533 #ub04id20{left:720px; top:110px; width:34px;  text-align:left;}
 534 #ub04id21{left:764px; top:110px; width:110px;  text-align:left;}
 535 #ub04id22{left:885px; top:110px; width:34px;  text-align:left;}
 536 #ub04id23{left:15px;  top:147px; width:99px;  text-align:right;}
 537 #ub04id24{left:115px; top:147px; width:34px;  text-align:center;}
 538 #ub04id25{left:148px; top:147px; width:66px;  text-align:right;}
 539 #ub04id26{left:214px; top:147px; width:32px;  text-align:center;}
 540 #ub04id27{left:246px; top:147px; width:34px;  text-align:center;}
 541 #ub04id28{left:280px; top:147px; width:32px;  text-align:center;}
 542 #ub04id29{left:312px; top:147px; width:34px;  text-align:center;}
 543 #ub04id30{left:345px; top:147px; width:34px;  text-align:right;}
 544 #ub04id31{left:378px; top:147px; width:34px;  text-align:center;}
 545 #ub04id32{left:411px; top:147px; width:34px;  text-align:center;}
 546 #ub04id33{left:445px; top:147px; width:34px;  text-align:center;}
 547 #ub04id34{left:477px; top:147px; width:34px;  text-align:center;}
 548 #ub04id35{left:510px; top:147px; width:34px;  text-align:center;}
 549 #ub04id36{left:543px; top:147px; width:34px;  text-align:center;}
 550 #ub04id37{left:576px; top:147px; width:34px;  text-align:center;}
 551 #ub04id38{left:610px; top:147px; width:34px;  text-align:center;}
 552 #ub04id39{left:643px; top:147px; width:34px;  text-align:center;}
 553 #ub04id40{left:675px; top:147px; width:34px;  text-align:center;}
 554 #ub04id41{left:709px; top:147px; width:32px;  text-align:center;}
 555 #ub04id42{left:741px; top:147px; width:37px;  text-align:center;}
 556 #ub04id43{left:778px; top:147px; width:141px;  text-align:left;}
 557 #ub04id44{left:15px;  top:184px; width:32px;  text-align:center;}
 558 #ub04id45{left:49px;  top:184px; width:77px;  text-align:right;}
 559 #ub04id46{left:125px; top:184px; width:32px;  text-align:center;}
 560 #ub04id47{left:159px; top:184px; width:77px;  text-align:right;}
 561 #ub04id48{left:235px; top:184px; width:32px;  text-align:center;}
 562 #ub04id49{left:269px; top:184px; width:77px;  text-align:right;}
 563 #ub04id50{left:345px; top:184px; width:34px;  text-align:center;}
 564 #ub04id51{left:379px; top:184px; width:77px;  text-align:right;}
 565 #ub04id52{left:455px; top:184px; width:34px;  text-align:center;}
 566 #ub04id53{left:489px; top:184px; width:77px;  text-align:right;}
 567 #ub04id54{left:567px; top:184px; width:77px;  text-align:right;}
 568 #ub04id55{left:643px; top:184px; width:32px;  text-align:center;}
 569 #ub04id56{left:677px; top:184px; width:77px;  text-align:right;}
 570 #ub04id57{left:755px; top:184px; width:77px;  text-align:right;}
 571 #ub04id58{left:831px; top:184px; width:87px;  text-align:center;}
 572 #ub04id59{left:15px;  top:202px; width:32px;  text-align:center;}
 573 #ub04id60{left:49px;  top:202px; width:77px;  text-align:right;}
 574 #ub04id61{left:125px; top:202px; width:32px;  text-align:center;}
 575 #ub04id62{left:159px; top:202px; width:77px;  text-align:right;}
 576 #ub04id63{left:235px; top:202px; width:32px;  text-align:center;}
 577 #ub04id64{left:269px; top:202px; width:77px;  text-align:right;}
 578 #ub04id65{left:345px; top:202px; width:34px;  text-align:center;}
 579 #ub04id66{left:379px; top:202px; width:77px;  text-align:right;}
 580 #ub04id67{left:455px; top:202px; width:34px;  text-align:center;}
 581 #ub04id68{left:489px; top:202px; width:77px;  text-align:right;}
 582 #ub04id69{left:567px; top:202px; width:77px;  text-align:right;}
 583 #ub04id70{left:643px; top:202px; width:32px;  text-align:center;}
 584 #ub04id71{left:677px; top:202px; width:77px;  text-align:right;}
 585 #ub04id72{left:755px; top:202px; width:77px;  text-align:right;}
 586 #ub04id73{left:831px; top:202px; width:87px;  text-align:center;}
 587 #ub04id74{left:489px; top:240px; width:32px;  text-align:center;}
 588 #ub04id75{left:523px; top:240px; width:110px;  text-align:right;}
 589 #ub04id76{left:631px; top:240px; width:34px;  text-align:center;}
 590 #ub04id77{left:666px; top:240px; width:110px;  text-align:right;}
 591 #ub04id78{left:775px; top:240px; width:34px;  text-align:center;}
 592 #ub04id79{left:808px; top:240px; width:110px;  text-align:right;}
 593 #ub04id80{left:489px; top:258px; width:32px;  text-align:center;}
 594 #ub04id81{left:523px; top:258px; width:110px;  text-align:right;}
 595 #ub04id82{left:631px; top:258px; width:34px;  text-align:center;}
 596 #ub04id83{left:666px; top:258px; width:110px;  text-align:right;}
 597 #ub04id84{left:775px; top:258px; width:34px;  text-align:center;}
 598 #ub04id85{left:808px; top:258px; width:110px;  text-align:right;}
 599 #ub04id86{left:489px; top:275px; width:32px;  text-align:center;}
 600 #ub04id87{left:523px; top:275px; width:110px;  text-align:right;}
 601 #ub04id88{left:631px; top:275px; width:34px;  text-align:center;}
 602 #ub04id89{left:666px; top:275px; width:110px;  text-align:right;}
 603 #ub04id90{left:775px; top:275px; width:34px;  text-align:center;}
 604 #ub04id91{left:808px; top:275px; width:110px;  text-align:right;}
 605 #ub04id92{left:489px; top:294px; width:32px;  text-align:center;}
 606 #ub04id93{left:523px; top:294px; width:110px;  text-align:right;}
 607 #ub04id94{left:631px; top:294px; width:34px;  text-align:center;}
 608 #ub04id95{left:666px; top:294px; width:110px;  text-align:right;}
 609 #ub04id96{left:775px; top:294px; width:34px;  text-align:center;}
 610 #ub04id97{left:808px; top:294px; width:110px;  text-align:right;}
 611 #ub04id98{z-index:2; resize:none; position: absolute; left:31px; top:220px; width:448px; height:87px; color: rgb(0,0,0); text-align:left;}
 612 #ub04id99{left:15px;  top:332px; width:52px;  text-align:center;}
 613 #ub04id100{left:67px;  top:332px; width:274px;  text-align:left;}
 614 #ub04id101{left:342px; top:332px; width:164px;  text-align:center;}
 615 #ub04id102{left:507px; top:332px; width:77px;  text-align:right;}
 616 #ub04id103{left:585px; top:332px; width:86px;  text-align:right;}
 617 #ub04id104{left:672px; top:332px; width:110px;  text-align:right;}
 618 #ub04id105{left:782px; top:332px; width:109px;  text-align:right;}
 619 #ub04id106{left:891px; top:332px; width:28px;  text-align:center;}
 620 #ub04id107{left:15px;  top:349px; width:52px;  text-align:center;}
 621 #ub04id108{left:67px;  top:349px; width:274px;  text-align:left;}
 622 #ub04id109{left:342px; top:349px; width:164px;  text-align:center;}
 623 #ub04id110{left:507px; top:349px; width:77px;  text-align:right;}
 624 #ub04id111{left:585px; top:349px; width:86px;  text-align:right;}
 625 #ub04id112{left:672px; top:349px; width:110px;  text-align:right;}
 626 #ub04id113{left:782px; top:349px; width:109px;  text-align:right;}
 627 #ub04id114{left:891px; top:349px; width:28px;  text-align:center;}
 628 #ub04id115{left:15px;  top:368px; width:52px;  text-align:center;}
 629 #ub04id116{left:67px;  top:368px; width:274px;  text-align:left;}
 630 #ub04id117{left:342px; top:368px; width:164px;  text-align:center;}
 631 #ub04id118{left:507px; top:368px; width:77px;  text-align:right;}
 632 #ub04id119{left:585px; top:368px; width:86px;  text-align:right;}
 633 #ub04id120{left:672px; top:368px; width:110px;  text-align:right;}
 634 #ub04id121{left:782px; top:368px; width:109px;  text-align:right;}
 635 #ub04id122{left:891px; top:368px; width:28px;  text-align:center;}
 636 #ub04id123{left:15px;  top:385px; width:52px;  text-align:center;}
 637 #ub04id124{left:67px;  top:385px; width:274px;  text-align:left;}
 638 #ub04id125{left:342px; top:385px; width:164px;  text-align:center;}
 639 #ub04id126{left:507px; top:385px; width:77px;  text-align:right;}
 640 #ub04id127{left:585px; top:385px; width:86px;  text-align:right;}
 641 #ub04id128{left:672px; top:385px; width:110px;  text-align:right;}
 642 #ub04id129{left:782px; top:385px; width:109px;  text-align:right;}
 643 #ub04id130{left:891px; top:385px; width:28px;  text-align:center;}
 644 #ub04id131{left:15px;  top:404px; width:52px;  text-align:center;}
 645 #ub04id132{left:67px;  top:404px; width:274px;  text-align:left;}
 646 #ub04id133{left:342px; top:404px; width:164px;  text-align:center;}
 647 #ub04id134{left:507px; top:404px; width:77px;  text-align:right;}
 648 #ub04id135{left:585px; top:404px; width:86px;  text-align:right;}
 649 #ub04id136{left:672px; top:404px; width:110px;  text-align:right;}
 650 #ub04id137{left:782px; top:404px; width:109px;  text-align:right;}
 651 #ub04id138{left:891px; top:404px; width:28px;  text-align:center;}
 652 #ub04id139{left:15px;  top:422px; width:52px;  text-align:center;}
 653 #ub04id140{left:67px;  top:422px; width:274px;  text-align:left;}
 654 #ub04id141{left:342px; top:422px; width:164px;  text-align:center;}
 655 #ub04id142{left:507px; top:422px; width:77px;  text-align:right;}
 656 #ub04id143{left:585px; top:422px; width:86px;  text-align:right;}
 657 #ub04id144{left:672px; top:422px; width:110px;  text-align:right;}
 658 #ub04id145{left:782px; top:422px; width:109px;  text-align:right;}
 659 #ub04id146{left:891px; top:422px; width:28px;  text-align:center;}
 660 #ub04id147{left:15px;  top:440px; width:52px;  text-align:center;}
 661 #ub04id148{left:67px;  top:440px; width:274px;  text-align:left;}
 662 #ub04id149{left:342px; top:440px; width:164px;  text-align:center;}
 663 #ub04id150{left:507px; top:440px; width:77px;  text-align:right;}
 664 #ub04id151{left:585px; top:440px; width:86px;  text-align:right;}
 665 #ub04id152{left:672px; top:440px; width:110px;  text-align:right;}
 666 #ub04id153{left:782px; top:440px; width:109px;  text-align:right;}
 667 #ub04id154{left:891px; top:440px; width:28px;  text-align:center;}
 668 #ub04id155{left:15px;  top:459px; width:52px;  text-align:center;}
 669 #ub04id156{left:67px;  top:459px; width:274px;  text-align:left;}
 670 #ub04id157{left:342px; top:459px; width:164px;  text-align:center;}
 671 #ub04id158{left:507px; top:459px; width:77px;  text-align:right;}
 672 #ub04id159{left:585px; top:459px; width:86px;  text-align:right;}
 673 #ub04id160{left:672px; top:459px; width:110px;  text-align:right;}
 674 #ub04id161{left:782px; top:459px; width:109px;  text-align:right;}
 675 #ub04id162{left:891px; top:459px; width:28px;  text-align:center;}
 676 #ub04id163{left:15px;  top:477px; width:52px;  text-align:center;}
 677 #ub04id164{left:67px;  top:477px; width:274px;  text-align:left;}
 678 #ub04id165{left:342px; top:477px; width:164px;  text-align:center;}
 679 #ub04id166{left:507px; top:477px; width:77px;  text-align:right;}
 680 #ub04id167{left:585px; top:477px; width:86px;  text-align:right;}
 681 #ub04id168{left:672px; top:477px; width:110px;  text-align:right;}
 682 #ub04id169{left:782px; top:477px; width:109px;  text-align:right;}
 683 #ub04id170{left:891px; top:477px; width:28px;  text-align:center;}
 684 #ub04id171{left:15px;  top:495px; width:52px;  text-align:center;}
 685 #ub04id172{left:67px;  top:495px; width:274px;  text-align:left;}
 686 #ub04id173{left:342px; top:495px; width:164px;  text-align:center;}
 687 #ub04id174{left:507px; top:495px; width:77px;  text-align:right;}
 688 #ub04id175{left:585px; top:495px; width:86px;  text-align:right;}
 689 #ub04id176{left:672px; top:495px; width:110px;  text-align:right;}
 690 #ub04id177{left:782px; top:495px; width:109px;  text-align:right;}
 691 #ub04id178{left:891px; top:495px; width:28px;  text-align:center;}
 692 #ub04id179{left:15px;  top:514px; width:52px;  text-align:center;}
 693 #ub04id180{left:67px;  top:514px; width:274px;  text-align:left;}
 694 #ub04id181{left:342px; top:514px; width:164px;  text-align:center;}
 695 #ub04id182{left:507px; top:514px; width:77px;  text-align:right;}
 696 #ub04id183{left:585px; top:514px; width:86px;  text-align:right;}
 697 #ub04id184{left:672px; top:514px; width:110px;  text-align:right;}
 698 #ub04id185{left:782px; top:514px; width:109px;  text-align:right;}
 699 #ub04id186{left:891px; top:514px; width:28px;  text-align:center;}
 700 #ub04id187{left:15px;  top:532px; width:52px;  text-align:center;}
 701 #ub04id188{left:67px;  top:532px; width:274px;  text-align:left;}
 702 #ub04id189{left:342px; top:532px; width:164px;  text-align:center;}
 703 #ub04id190{left:507px; top:532px; width:77px;  text-align:right;}
 704 #ub04id191{left:585px; top:532px; width:86px;  text-align:right;}
 705 #ub04id192{left:672px; top:532px; width:110px;  text-align:right;}
 706 #ub04id193{left:782px; top:532px; width:109px;  text-align:right;}
 707 #ub04id194{left:891px; top:532px; width:28px;  text-align:center;}
 708 #ub04id195{left:15px;  top:550px; width:52px;  text-align:center;}
 709 #ub04id196{left:67px;  top:550px; width:274px;  text-align:left;}
 710 #ub04id197{left:342px; top:550px; width:164px;  text-align:center;}
 711 #ub04id198{left:507px; top:550px; width:77px;  text-align:right;}
 712 #ub04id199{left:585px; top:550px; width:86px;  text-align:right;}
 713 #ub04id200{left:672px; top:550px; width:110px;  text-align:right;}
 714 #ub04id201{left:782px; top:550px; width:109px;  text-align:right;}
 715 #ub04id202{left:891px; top:550px; width:28px;  text-align:center;}
 716 #ub04id203{left:15px;  top:569px; width:52px;  text-align:center;}
 717 #ub04id204{left:67px;  top:569px; width:274px;  text-align:left;}
 718 #ub04id205{left:342px; top:569px; width:164px;  text-align:center;}
 719 #ub04id206{left:507px; top:569px; width:77px;  text-align:right;}
 720 #ub04id207{left:585px; top:569px; width:86px;  text-align:right;}
 721 #ub04id208{left:672px; top:569px; width:110px;  text-align:right;}
 722 #ub04id209{left:782px; top:569px; width:109px;  text-align:right;}
 723 #ub04id210{left:891px; top:569px; width:28px;  text-align:center;}
 724 #ub04id211{left:15px;  top:587px; width:52px;  text-align:center;}
 725 #ub04id212{left:67px;  top:587px; width:274px;  text-align:left;}
 726 #ub04id213{left:342px; top:587px; width:164px;  text-align:center;}
 727 #ub04id214{left:507px; top:587px; width:77px;  text-align:right;}
 728 #ub04id215{left:585px; top:587px; width:86px;  text-align:right;}
 729 #ub04id216{left:672px; top:587px; width:110px;  text-align:right;}
 730 #ub04id217{left:782px; top:587px; width:109px;  text-align:right;}
 731 #ub04id218{left:891px; top:587px; width:28px;  text-align:center;}
 732 #ub04id219{left:15px;  top:605px; width:52px;  text-align:center;}
 733 #ub04id220{left:67px;  top:605px; width:274px;  text-align:left;}
 734 #ub04id221{left:342px; top:605px; width:164px;  text-align:center;}
 735 #ub04id222{left:507px; top:605px; width:77px;  text-align:right;}
 736 #ub04id223{left:585px; top:605px; width:86px;  text-align:right;}
 737 #ub04id224{left:672px; top:605px; width:110px;  text-align:right;}
 738 #ub04id225{left:782px; top:605px; width:109px;  text-align:right;}
 739 #ub04id226{left:891px; top:605px; width:28px;  text-align:center;}
 740 #ub04id227{left:15px;  top:624px; width:52px;  text-align:center;}
 741 #ub04id228{left:67px;  top:624px; width:274px;  text-align:left;}
 742 #ub04id229{left:342px; top:624px; width:164px;  text-align:center;}
 743 #ub04id230{left:507px; top:624px; width:77px;  text-align:right;}
 744 #ub04id231{left:585px; top:624px; width:86px;  text-align:right;}
 745 #ub04id232{left:672px; top:624px; width:110px;  text-align:right;}
 746 #ub04id233{left:782px; top:624px; width:109px;  text-align:right;}
 747 #ub04id234{left:891px; top:624px; width:28px;  text-align:center;}
 748 #ub04id235{left:15px;  top:642px; width:52px;  text-align:center;}
 749 #ub04id236{left:67px;  top:642px; width:274px;  text-align:left;}
 750 #ub04id237{left:342px; top:642px; width:164px;  text-align:center;}
 751 #ub04id238{left:507px; top:642px; width:77px;  text-align:right;}
 752 #ub04id239{left:585px; top:642px; width:86px;  text-align:right;}
 753 #ub04id240{left:672px; top:642px; width:110px;  text-align:right;}
 754 #ub04id241{left:782px; top:642px; width:109px;  text-align:right;}
 755 #ub04id242{left:891px; top:642px; width:28px;  text-align:center;}
 756 #ub04id243{left:15px;  top:660px; width:52px;  text-align:center;}
 757 #ub04id244{left:67px;  top:660px; width:274px;  text-align:left;}
 758 #ub04id245{left:342px; top:660px; width:164px;  text-align:center;}
 759 #ub04id246{left:507px; top:660px; width:77px;  text-align:right;}
 760 #ub04id247{left:585px; top:660px; width:86px;  text-align:right;}
 761 #ub04id248{left:672px; top:660px; width:110px;  text-align:right;}
 762 #ub04id249{left:782px; top:660px; width:109px;  text-align:right;}
 763 #ub04id250{left:891px; top:660px; width:28px;  text-align:center;}
 764 #ub04id251{left:15px;  top:679px; width:52px;  text-align:center;}
 765 #ub04id252{left:67px;  top:679px; width:274px;  text-align:left;}
 766 #ub04id253{left:342px; top:679px; width:164px;  text-align:center;}
 767 #ub04id254{left:507px; top:679px; width:77px;  text-align:right;}
 768 #ub04id255{left:585px; top:679px; width:86px;  text-align:right;}
 769 #ub04id256{left:672px; top:679px; width:110px;  text-align:right;}
 770 #ub04id257{left:782px; top:679px; width:109px;  text-align:right;}
 771 #ub04id258{left:891px; top:679px; width:28px;  text-align:center;}
 772 #ub04id259{left:15px;  top:697px; width:52px;  text-align:center;}
 773 #ub04id260{left:67px;  top:697px; width:274px;  text-align:left;}
 774 #ub04id261{left:342px; top:697px; width:164px;  text-align:center;}
 775 #ub04id262{left:507px; top:697px; width:77px;  text-align:right;}
 776 #ub04id263{left:585px; top:697px; width:86px;  text-align:right;}
 777 #ub04id264{left:672px; top:697px; width:110px;  text-align:right;}
 778 #ub04id265{left:782px; top:697px; width:109px;  text-align:right;}
 779 #ub04id266{left:891px; top:697px; width:28px;  text-align:center;}
 780 #ub04id267{left:15px;  top:715px; width:52px;  text-align:center;}
 781 #ub04id268{left:67px;  top:715px; width:274px;  text-align:left;}
 782 #ub04id269{left:342px; top:715px; width:164px;  text-align:center;}
 783 #ub04id270{left:507px; top:715px; width:77px;  text-align:right;}
 784 #ub04id271{left:585px; top:715px; width:86px;  text-align:right;}
 785 #ub04id272{left:672px; top:715px; width:110px;  text-align:right;}
 786 #ub04id273{left:782px; top:715px; width:109px;  text-align:right;}
 787 #ub04id274{left:891px; top:715px; width:28px;  text-align:center;}
 788 #ub04id275{left:15px;  top:734px; width:52px;  text-align:center;}
 789 #ub04id276{left:118px; top:734px; width:32px;  text-align:center;}
 790 #ub04id277{left:182px; top:734px; width:32px;  text-align:center;}
 791 #ub04id278{left:507px; top:734px; width:77px;  text-align:center;}
 792 #ub04id279{left:672px; top:734px; width:110px;  text-align:right;}
 793 #ub04id280{left:782px; top:734px; width:109px;  text-align:right;}
 794 #ub04id281{left:891px; top:734px; width:28px;  text-align:center;}
 795 #ub04id282{left:753px; top:752px; width:165px;  text-align:left;}
 796 #ub04id283{left:15px;  top:770px; width:252px;  text-align:left;}
 797 #ub04id284{left:269px; top:770px; width:164px;  text-align:left;}
 798 #ub04id285{left:434px; top:770px; width:22px;  text-align:left;}
 799 #ub04id286{left:468px; top:770px; width:20px;  text-align:left;}
 800 #ub04id287{left:489px; top:770px; width:110px;  text-align:right;}
 801 #ub04id288{left:599px; top:770px; width:121px;  text-align:right;}
 802 #ub04id289{left:753px; top:770px; width:165px;  text-align:left;}
 803 #ub04id290{left:15px;  top:789px; width:252px;  text-align:left;}
 804 #ub04id291{left:269px; top:789px; width:164px;  text-align:left;}
 805 #ub04id292{left:434px; top:789px; width:22px;  text-align:left;}
 806 #ub04id293{left:468px; top:789px; width:20px;  text-align:left;}
 807 #ub04id294{left:489px; top:789px; width:110px;  text-align:right;}
 808 #ub04id295{left:599px; top:789px; width:121px;  text-align:right;}
 809 #ub04id296{left:753px; top:789px; width:165px;  text-align:left;}
 810 #ub04id297{left:15px;  top:807px; width:252px;  text-align:left;}
 811 #ub04id298{left:269px; top:807px; width:164px;  text-align:left;}
 812 #ub04id299{left:434px; top:807px; width:22px;  text-align:left;}
 813 #ub04id300{left:468px; top:807px; width:20px;  text-align:left;}
 814 #ub04id301{left:489px; top:807px; width:110px;  text-align:right;}
 815 #ub04id302{left:599px; top:807px; width:121px;  text-align:right;}
 816 #ub04id303{left:753px; top:807px; width:165px;  text-align:left;}
 817 #ub04id304{left:15px;  top:845px; width:286px;  text-align:left;}
 818 #ub04id305{left:301px; top:845px; width:32px;  text-align:left;}
 819 #ub04id306{left:333px; top:845px; width:220px;  text-align:left;}
 820 #ub04id307{left:555px; top:845px; width:165px;  text-align:left;}
 821 #ub04id308{left:720px; top:845px; width:199px;  text-align:left;}
 822 #ub04id309{left:15px;  top:862px; width:286px;  text-align:left;}
 823 #ub04id310{left:301px; top:862px; width:32px;  text-align:left;}
 824 #ub04id311{left:333px; top:862px; width:220px;  text-align:left;}
 825 #ub04id312{left:555px; top:862px; width:165px;  text-align:left;}
 826 #ub04id313{left:720px; top:862px; width:199px;  text-align:left;}
 827 #ub04id314{left:15px;  top:880px; width:286px;  text-align:left;}
 828 #ub04id315{left:301px; top:880px; width:32px;  text-align:left;}
 829 #ub04id316{left:333px; top:880px; width:220px;  text-align:left;}
 830 #ub04id317{left:555px; top:880px; width:165px;  text-align:left;}
 831 #ub04id318{left:720px; top:880px; width:199px;  text-align:left;}
 832 #ub04id319{left:15px;  top:917px; width:341px;  text-align:left;}
 833 #ub04id320{left:358px; top:917px; width:286px;  text-align:left;}
 834 #ub04id321{left:643px; top:917px; width:275px;  text-align:left;}
 835 #ub04id322{left:15px;  top:935px; width:341px;  text-align:left;}
 836 #ub04id323{left:358px; top:935px; width:286px;  text-align:left;}
 837 #ub04id324{left:643px; top:935px; width:275px;  text-align:left;}
 838 #ub04id325{left:15px;  top:954px; width:341px;  text-align:left;}
 839 #ub04id326{left:358px; top:954px; width:286px;  text-align:left;}
 840 #ub04id327{left:643px; top:954px; width:275px;  text-align:left;}
 841 #ub04id328{left:28px;  top:972px; width:77px;  text-align:left;}
 842 #ub04id329{left:106px; top:972px; width:11px;  text-align:center;}
 843 #ub04id330{left:115px; top:972px; width:78px;  text-align:left;}
 844 #ub04id331{left:193px; top:972px; width:12px;  text-align:center;}
 845 #ub04id332{left:203px; top:972px; width:78px;  text-align:left;}
 846 #ub04id333{left:280px; top:972px; width:12px;  text-align:center;}
 847 #ub04id334{left:290px; top:972px; width:78px;  text-align:left;}
 848 #ub04id335{left:368px; top:972px; width:12px;  text-align:center;}
 849 #ub04id336{left:381px; top:972px; width:77px;  text-align:left;}
 850 #ub04id337{left:457px; top:972px; width:11px;  text-align:center;}
 851 #ub04id338{left:468px; top:972px; width:77px;  text-align:left;}
 852 #ub04id339{left:544px; top:972px; width:12px;  text-align:center;}
 853 #ub04id340{left:556px; top:972px; width:77px;  text-align:left;}
 854 #ub04id341{left:633px; top:972px; width:12px;  text-align:center;}
 855 #ub04id342{left:643px; top:972px; width:78px;  text-align:left;}
 856 #ub04id343{left:721px; top:972px; width:11px;  text-align:center;}
 857 #ub04id344{left:732px; top:972px; width:78px;  text-align:left;}
 858 #ub04id345{left:810px; top:972px; width:11px;  text-align:center;}
 859 #ub04id346{left:833px; top:972px; width:86px;  text-align:left;}
 860 #ub04id347{left:15px;  top:990px; width:11px;  text-align:center;}
 861 #ub04id348{left:28px;  top:990px; width:77px;  text-align:left;}
 862 #ub04id349{left:106px; top:990px; width:11px;  text-align:center;}
 863 #ub04id350{left:115px; top:990px; width:78px;  text-align:left;}
 864 #ub04id351{left:193px; top:990px; width:12px;  text-align:center;}
 865 #ub04id352{left:203px; top:990px; width:78px;  text-align:left;}
 866 #ub04id353{left:280px; top:990px; width:12px;  text-align:center;}
 867 #ub04id354{left:290px; top:990px; width:78px;  text-align:left;}
 868 #ub04id355{left:368px; top:990px; width:12px;  text-align:center;}
 869 #ub04id356{left:381px; top:990px; width:77px;  text-align:left;}
 870 #ub04id357{left:457px; top:990px; width:11px;  text-align:center;}
 871 #ub04id358{left:468px; top:990px; width:78px;  text-align:left;}
 872 #ub04id359{left:544px; top:990px; width:12px;  text-align:center;}
 873 #ub04id360{left:556px; top:990px; width:77px;  text-align:left;}
 874 #ub04id361{left:633px; top:990px; width:12px;  text-align:center;}
 875 #ub04id362{left:643px; top:990px; width:78px;  text-align:left;}
 876 #ub04id363{left:732px; top:990px; width:78px;  text-align:left;}
 877 #ub04id364{left:810px; top:990px; width:11px;  text-align:center;}
 878 #ub04id365{left:821px; top:990px; width:98px;  text-align:left;}
 879 #ub04id366{left:721px; top:990px; width:11px;  text-align:center;}
 880 #ub04id367{left:58px;  top:1010px; width:80px;  text-align:left;}
 881 #ub04id368{left:193px; top:1010px; width:77px;  text-align:center;}
 882 #ub04id369{left:269px; top:1010px; width:77px;  text-align:center;}
 883 #ub04id370{left:347px; top:1010px; width:77px;  text-align:center;}
 884 #ub04id371{left:468px; top:1010px; width:55px;  text-align:right;}
 885 #ub04id372{left:544px; top:1010px; width:78px;  text-align:center;}
 886 #ub04id373{left:622px; top:1010px; width:11px;  text-align:center;}
 887 #ub04id374{left:633px; top:1010px; width:77px;  text-align:center;}
 888 #ub04id375{left:711px; top:1010px; width:11px;  text-align:center;}
 889 #ub04id376{left:721px; top:1010px; width:77px;  text-align:center;}
 890 #ub04id377{left:798px; top:1010px; width:12px;  text-align:center;}
 891 #ub04id378{left:824px; top:1010px; width:95px;  text-align:left;}
 892 #ub04id379{left:662px; top:1028px; width:113px;  text-align:left;}
 893 #ub04id380{left:798px; top:1028px; width:23px;  text-align:left;}
 894 #ub04id381{left:821px; top:1028px; width:98px;  text-align:left;}
 895 #ub04id382{left:15px;  top:1045px; width:89px;  text-align:left;}
 896 #ub04id383{left:104px; top:1045px; width:77px;  text-align:right;}
 897 #ub04id384{left:182px; top:1045px; width:87px;  text-align:left;}
 898 #ub04id385{left:269px; top:1045px; width:77px;  text-align:right;}
 899 #ub04id386{left:347px; top:1045px; width:87px;  text-align:left;}
 900 #ub04id387{left:434px; top:1045px; width:77px;  text-align:right;}
 901 #ub04id388{left:594px; top:1045px; width:170px;  text-align:left;}
 902 #ub04id389{left:790px; top:1045px; width:129px;  text-align:left;}
 903 #ub04id390{left:662px; top:1065px; width:113px;  text-align:left;}
 904 #ub04id391{left:798px; top:1065px; width:23px;  text-align:left;}
 905 #ub04id392{left:821px; top:1065px; width:98px;  text-align:left;}
 906 #ub04id393{left:15px;  top:1082px; width:89px;  text-align:left;}
 907 #ub04id394{left:104px; top:1082px; width:77px;  text-align:right;}
 908 #ub04id395{left:182px; top:1082px; width:87px;  text-align:left;}
 909 #ub04id396{left:269px; top:1082px; width:77px;  text-align:right;}
 910 #ub04id397{left:347px; top:1082px; width:87px;  text-align:left;}
 911 #ub04id398{left:434px; top:1082px; width:77px;  text-align:right;}
 912 #ub04id399{resize:none; left:512px; top:1036px; width:55px; height:60px; color: rgb(0,0,0); text-align:left;}
 913 #ub04id400{left:594px; top:1082px; width:170px;  text-align:left;}
 914 #ub04id401{left:790px; top:1082px; width:129px;  text-align:left;}
 915 #ub04id402{left:303px; top:1102px; width:20px;  text-align:center;}
 916 #ub04id403{left:324px; top:1102px; width:110px;  text-align:left;}
 917 #ub04id404{left:436px; top:1102px; width:132px;  text-align:right;}
 918 #ub04id405{left:622px; top:1102px; width:22px;  text-align:left;}
 919 #ub04id406{left:662px; top:1102px; width:113px;  text-align:left;}
 920 #ub04id407{left:798px; top:1102px; width:23px;  text-align:left;}
 921 #ub04id408{left:821px; top:1102px; width:98px;  text-align:left;}
 922 #ub04id409{left:72px;  top:1102px; width:209px;  text-align:left;}
 923 #ub04id410{left:303px; top:1120px; width:20px;  text-align:center;}
 924 #ub04id411{left:324px; top:1120px; width:110px;  text-align:left;}
 925 #ub04id412{left:436px; top:1120px; width:132px;  text-align:right;}
 926 #ub04id413{left:594px; top:1120px; width:170px;  text-align:left;}
 927 #ub04id414{left:790px; top:1120px; width:129px;  text-align:left;}
 928 #ub04id415{left:19px;  top:1120px; width:263px;  text-align:left;}
 929 #ub04id416{left:303px; top:1137px; width:20px;  text-align:center;}
 930 #ub04id417{left:324px; top:1137px; width:110px;  text-align:left;}
 931 #ub04id418{left:436px; top:1137px; width:132px;  text-align:right;}
 932 #ub04id419{left:622px; top:1137px; width:22px;  text-align:left;}
 933 #ub04id420{left:662px; top:1137px; width:113px;  text-align:left;}
 934 #ub04id421{left:821px; top:1137px; width:98px;  text-align:left;}
 935 #ub04id422{left:798px; top:1137px; width:23px;  text-align:left;}
 936 #ub04id423{left:19px;  top:1137px; width:263px;  text-align:left;}
 937 #ub04id424{left:303px; top:1155px; width:20px;  text-align:center;}
 938 #ub04id425{left:324px; top:1155px; width:110px;  text-align:left;}
 939 #ub04id426{left:436px; top:1155px; width:132px;  text-align:right;}
 940 #ub04id427{left:594px; top:1155px; width:170px;  text-align:left;}
 941 #ub04id428{left:790px; top:1155px; width:129px;  text-align:left;}
 942 #ub04id429{left:19px;  top:1155px; width:263px;  text-align:left;}
 943 </style>
 944 </head>
 945 <body onload="adjustForm();">
 946 <div class="container" id="formContainer">
 947 <?php if ($isAuthorized !== true) {?>
 948 <h3 class='formhide'><em><?php echo xlt('Claim Edit') ?> </em><button class="btn btn-xs btn-warning" onclick="myZoom()" ><?php echo xlt('Zoom'); ?></button></h3>
 949 <div class="navbar-fixed-top formhide" id='menu'>
 950 <?php if ($pid && $encounter) {?>
 951     <button class="btn btn-xs btn-success" onclick="disposeSave('form')" title=<?php echo xla("Save for printing with form") ?>><?php echo xlt('Pdf With Form'); ?></button>
 952     <button class="btn btn-xs btn-success" onclick="disposeSave('noform')" title=<?php echo xla("Save for printing to a pre printed sheet"); ?>><?php echo xlt('Pdf Without Form'); ?></button>
 953     <button class="btn btn-xs btn-success" onclick="postClaim('batch_save')" title=<?php echo xla("Save claim for batch processing"); ?>><?php echo xlt('Save Claim'); ?></button>
 954     <?php } else {?>
 955     <button class="btn btn-xs btn-success" onclick="postClaim('payer_save')"><?php echo xlt('Save Payer'); ?></button>
 956     <?php } ?>
 957     <button class="btn btn-xs btn-danger" onclick="resetClaim()" title=<?php echo xla("Reset claim form to Fee Sheet Version"); ?>><?php echo xlt('Reset Version'); ?></button>
 958     <button class="btn btn-info btn-xs" type="button" onclick="window.scrollTo(0, 0);$('#formhelp').toggle()"><?php echo xlt('Help'); ?></button>
 959     <button class="btn btn-xs btn-danger" onclick="cleanUp()"><?php echo xlt('Return'); ?></button>
 960 </div>
 961 <div id='formhelp' class='well' style='display:none; text-align:center; width: auto; margin: 5px auto;'>
 962     <h4>Help</h4>
 963      <div style='text-align:left;'>
 964         * <?php echo xlt('Many code items have a lookup/hint.'); ?>
 965         <?php echo xlt('Either type a search term in appropriate box or double click box to see available codes.'); ?><br>
 966         * <?php echo xlt('Double Clicking a NPI box will bring up a current Users dialog for providers.'); ?><br>
 967         * <?php echo xlt('PDF buttons will save, mark claim reviewed and download claim'); ?><br>
 968         * <?php echo xlt('Reset button resets the edited claim to the fee sheet version. If subsequently saved, it will replace last claim version and be considered reviewed. Otherwise, claim is reset to fee sheet version.'); ?><br>
 969         * <?php echo xlt('Save button saves claim and marks reviewed'); ?><br>
 970         * <?php echo xlt('Return button simply returns, then refreshes billing manager'); ?><br><br>
 971     </div>
 972    <button class="btn btn-primary btn-xs" type="button" onclick="$('#formhelp').toggle()"><?php echo xlt('Dismiss Help'); ?></button>
 973 </div>
 974 <?php } ?>
 975 <div id="p1" class="pageArea" style="overflow: hidden; position: relative; width: 934px; height: 1210px;">
 976 <!-- Template background -->
 977 <div id="pg1" style="-webkit-user-select: none;"><img src="<?php echo $imgurl ?>/ub04.svg" id="frmbg" style="width:934px; height:1210px; background-color:white; -moz-transform:scale(1); z-index: 0;" /></div>
 978 <!-- Begin Form Data -->
 979 <form id="ub04Data">
 980 <input type="text"   maxlength="25"  id="ub04id1" value=""  title="2. PAY-TO NAME"  name="ub04Block_4"/>
 981 <input type="text"   maxlength="25"  id="ub04id2" value=""  title="1. BILLING PROVIDER NAME"  name="ub04Block_0"/>
 982 <input type="text"   maxlength="20"  id="ub04id3" value=""  title="3a. PATIENT CONTROL NUMBER"  name="ub04Block_8"/>
 983 <input type="text"   maxlength="25"  id="ub04id4" value=""  title="1. BILLING PROVIDER STREET ADDRESS"  name="ub04Block_1"/>
 984 <input type="text"   maxlength="25"  id="ub04id5" value=""  title="2. PAY-TO STREET ADDRESS"  name="ub04Block_5"/>
 985 <input type="text"   maxlength="24"  id="ub04id6" value=""  title="3b. MEDICAL/HEALTH RECORD NUMBER"  name="ub04Block_9"/>
 986 <input type="text"   maxlength="4"  id="ub04id7" value=""   title="4. TYPE OF BILL"  name="ub04Block_10"/>
 987 <input type="text"   maxlength="25"  id="ub04id8" value=""  title="1. BILLING PROVIDER CITY, STATE, ZIP"  name="ub04Block_2"/>
 988 <input type="text"   maxlength="25"  id="ub04id9" value=""  title="2. PAY-TO CITY, STATE, ZIP"  name="ub04Block_6"/>
 989 <input type="text"   maxlength="25"  id="ub04id10" value="" title="1. BILLING PROVIDER COUNTRY CODE, PHONE NUMBER"  name="ub04Block_3"/>
 990 <input type="text"   maxlength="25"  id="ub04id11" value="" title="2. PAY-TO COUNTRY CODE, PHONE NUMBER"  name="ub04Block_7"/>
 991 <input type="text"   maxlength="10"  id="ub04id12" value="" title="5. FEDERAL TAX NUMBER"  name="ub04Block_11"/>
 992 <input type="text" data-dp  maxlength="10"  id="ub04id13" value=""  title="6. STATEMENT COVERS PERIOD FROM DATE"  name="ub04Block_12"/>
 993 <input type="text" data-dp   maxlength="10"  id="ub04id14" value=""  title="6. STATEMENT COVERS PERIOD TO DATE"  name="ub04Block_13"/>
 994 <textarea  disabled maxlength="15"  id="ub04id15" title="7. RESERVED"  name="ub04Block_14"></textarea>
 995 <input type="text"   maxlength="19"  id="ub04id16" value="" title="8a. PATIENT IDENTIFIER"  name="ub04Block_15"/>
 996 <input type="text"   maxlength="40"  id="ub04id17" value="" title="9a. PATIENT STREET ADDRESS"  name="ub04Block_17"/>
 997 <input type="text"   maxlength="29"  id="ub04id18" value="" title="8b. PATIENT NAME"  name="ub04Block_16"/>
 998 <input type="text"   maxlength="30"  id="ub04id19" value="" title="9b. PATIENT CITY"  name="ub04Block_18"/>
 999 <input type="text"   maxlength="2"  id="ub04id20" value=""  title="9c. PATIENT STATE"  name="ub04Block_19"/>
1000 <input type="text"   maxlength="9"  id="ub04id21" value=""  title="9d. PATIENT ZIP CODE"  name="ub04Block_20"/>
1001 <input type="text"   maxlength="2"  id="ub04id22" value=""  title="9e. PATIENT COUNTRY CODE"  name="ub04Block_21"/>
1002 <input type="text"   maxlength="8"  id="ub04id23" value=""  title="10. PATIENT BIRTH DATE (MMDDYYYY)"  name="ub04Block_22"/>
1003 <input type="text"   maxlength="1"  id="ub04id24" value=""  title="11. PATIENT SEX"  name="ub04Block_23"/>
1004 <input type="text" data-dp   maxlength="10"  id="ub04id25" value=""  title="12. PATIENT ADMISSION/START OF CARE DATE (MMDDYY)"  name="ub04Block_24"/>
1005 <input type="text"   maxlength="2"  id="ub04id26" value=""  title="13. PATIENT ADMISSION HOUR"  name="ub04Block_25"/>
1006 <input type="text"   maxlength="1"  id="ub04id27" value=""  title="14. PATIENT PRIORITY (TYPE) OF VISIT"  name="ub04Block_26"/>
1007 <input type="text"   maxlength="1"  id="ub04id28" value=""  title="15. PATIENT POINT OF ORIGIN FOR ADMISSION OR VISIT"  name="ub04Block_27"/>
1008 <input type="text"   maxlength="2"  id="ub04id29" value=""  title="16. PATIENT DISCHARGE HOUR"  name="ub04Block_28"/>
1009 <input type="text"   maxlength="2"  id="ub04id30" value=""  title="17. PATIENT DISCHARGE STATUS"  name="ub04Block_29"/>
1010 <input type="text"   maxlength="2"  id="ub04id31" value=""  title="18. CONDITION CODE"  name="ub04Block_30"/>
1011 <input type="text"   maxlength="2"  id="ub04id32" value=""  title="19. CONDITION CODE"  name="ub04Block_31"/>
1012 <input type="text"   maxlength="2"  id="ub04id33" value=""  title="20. CONDITION CODE"  name="ub04Block_32"/>
1013 <input type="text"   maxlength="2"  id="ub04id34" value=""  title="21. CONDITION CODE"  name="ub04Block_33"/>
1014 <input type="text"   maxlength="2"  id="ub04id35" value=""  title="22. CONDITION CODE"  name="ub04Block_34"/>
1015 <input type="text"   maxlength="2"  id="ub04id36" value=""  title="23. CONDITION CODE"  name="ub04Block_35"/>
1016 <input type="text"   maxlength="2"  id="ub04id37" value=""  title="24. CONDITION CODE"  name="ub04Block_36"/>
1017 <input type="text"   maxlength="2"  id="ub04id38" value=""  title="25. CONDITION CODE"  name="ub04Block_37"/>
1018 <input type="text"   maxlength="2"  id="ub04id39" value=""  title="26. CONDITION CODE"  name="ub04Block_38"/>
1019 <input type="text"   maxlength="2"  id="ub04id40" value=""  title="27. CONDITION CODE"  name="ub04Block_39"/>
1020 <input type="text"   maxlength="2"  id="ub04id41" value=""  title="28. CONDITION CODE"  name="ub04Block_40"/>
1021 <input type="text"   maxlength="2"  id="ub04id42" value=""  title="29. ACCIDENT STATE"  name="ub04Block_41"/>
1022 <input type="text" disabled   id="ub04id43" value="" data-objref="520" title="30. RESERVED"  name="ub04Block_42"/>
1023 <input type="text"   maxlength="2"  id="ub04id44" value=""  title="31a. OCCURRENCE CODE"  name="ub04Block_43"/>
1024 <input type="text" data-dp   maxlength="10"  id="ub04id45" value=""  title="31a. OCCURRENCE DATE"  name="ub04Block_44"/>
1025 <input type="text"   maxlength="2"  id="ub04id46" value=""  title="32a. OCCURRENCE CODE"  name="ub04Block_45"/>
1026 <input type="text" data-dp   maxlength="10"  id="ub04id47" value=""  title="32a. OCCURRENCE DATE"  name="ub04Block_46"/>
1027 <input type="text"   maxlength="2"  id="ub04id48" value=""  title="33a. OCCURRENCE CODE"  name="ub04Block_47"/>
1028 <input type="text" data-dp   maxlength="10"  id="ub04id49" value=""  title="33a. OCCURRENCE DATE"  name="ub04Block_48"/>
1029 <input type="text"   maxlength="2"  id="ub04id50" value=""  title="34a. OCCURRENCE CODE"  name="ub04Block_49"/>
1030 <input type="text" data-dp  maxlength="10"  id="ub04id51" value=""  title="34a. OCCURRENCE DATE"  name="ub04Block_50"/>
1031 <input type="text"   maxlength="2"  id="ub04id52" value=""  title="35a. OCCURRENCE SPAN CODE"  name="ub04Block_59"/>
1032 <input type="text" data-dp   maxlength="10"  id="ub04id53" value=""  title="35a. OCCURRENCE SPAN DATE FROM"  name="ub04Block_60"/>
1033 <input type="text" data-dp  maxlength="10"  id="ub04id54" value=""  title="35a. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_61"/>
1034 <input type="text"   maxlength="2"  id="ub04id55" value=""  title="36a. OCCURRENCE SPAN CODE"  name="ub04Block_62"/>
1035 <input type="text" data-dp   maxlength="10"  id="ub04id56" value=""  title="36a. OCCURRENCE SPAN DATE FROM"  name="ub04Block_63"/>
1036 <input type="text" data-dp   maxlength="10"  id="ub04id57" value=""  title="36a. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_64"/>
1037 <input type="text" disabled  maxlength="8"  id="ub04id58" value=""  title="37a. RESERVED"  name="ub04Block_71"/>
1038 <input type="text"   maxlength="2"  id="ub04id59" value=""  title="31b. OCCURRENCE CODE"  name="ub04Block_51"/>
1039 <input type="text" data-dp  maxlength="10"  id="ub04id60" value=""  title="31b. OCCURRENCE DATE"  name="ub04Block_52"/>
1040 <input type="text"   maxlength="2"  id="ub04id61" value=""  title="32b. OCCURRENCE CODE"  name="ub04Block_53"/>
1041 <input type="text" data-dp  maxlength="10"  id="ub04id62" value=""  title="32b. OCCURRENCE DATE"  name="ub04Block_54"/>
1042 <input type="text"   maxlength="2"  id="ub04id63" value=""  title="33b. OCCURRENCE CODE"  name="ub04Block_55"/>
1043 <input type="text" data-dp  maxlength="10"  id="ub04id64" value=""  title="33b. OCCURRENCE DATE"  name="ub04Block_56"/>
1044 <input type="text"   maxlength="2"  id="ub04id65" value=""  title="34b. OCCURRENCE CODE"  name="ub04Block_57"/>
1045 <input type="text" data-dp   maxlength="10"  id="ub04id66" value=""  title="34b. OCCURRENCE DATE"  name="ub04Block_58"/>
1046 <input type="text"   maxlength="2"  id="ub04id67" value=""  title="35b. OCCURRENCE SPAN CODE"  name="ub04Block_65"/>
1047 <input type="text" data-dp   maxlength="10"  id="ub04id68" value=""  title="35b. OCCURRENCE SPAN DATE FROM"  name="ub04Block_66"/>
1048 <input type="text" data-dp   maxlength="10"  id="ub04id69" value=""  title="35b. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_67"/>
1049 <input type="text"   maxlength="2"  id="ub04id70" value=""  title="36b. OCCURRENCE SPAN CODE"  name="ub04Block_68"/>
1050 <input type="text" data-dp   maxlength="10"  id="ub04id71" value=""  title="36b. OCCURRENCE SPAN DATE FROM"  name="ub04Block_69"/>
1051 <input type="text" data-dp   maxlength="10"  id="ub04id72" value=""  title="36b. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_70"/>
1052 <input type="text" disabled  maxlength="8"  id="ub04id73" value=""  title="37b. RESERVED"  name="ub04Block_72"/>
1053 <input type="text"   maxlength="2"  id="ub04id74" value=""  title="39a. VALUE CODE"  name="ub04Block_74"/>
1054 <input type="text"   maxlength="9"  id="ub04id75" value=""  title="39a. VALUE AMOUNT"  name="ub04Block_75"/>
1055 <input type="text"   maxlength="2"  id="ub04id76" value=""  title="40a. VALUE CODE"  name="ub04Block_76"/>
1056 <input type="text"   maxlength="9"  id="ub04id77" value=""  title="40a. VALUE AMOUNT"  name="ub04Block_77"/>
1057 <input type="text"   maxlength="2"  id="ub04id78" value=""  title="41a. VALUE CODE"  name="ub04Block_78"/>
1058 <input type="text"   maxlength="9"  id="ub04id79" value=""  title="41a. VALUE AMOUNT"  name="ub04Block_79"/>
1059 <input type="text"   maxlength="2"  id="ub04id80" value=""  title="39b. VALUE CODE"  name="ub04Block_80"/>
1060 <input type="text"   maxlength="9"  id="ub04id81" value=""  title="39b. VALUE AMOUNT"  name="ub04Block_81"/>
1061 <input type="text"   maxlength="2"  id="ub04id82" value=""  title="40b. VALUE CODE"  name="ub04Block_82"/>
1062 <input type="text"   maxlength="9"  id="ub04id83" value=""  title="40b. VALUE AMOUNT"  name="ub04Block_83"/>
1063 <input type="text"   maxlength="2"  id="ub04id84" value=""  title="41b. VALUE CODE"  name="ub04Block_84"/>
1064 <input type="text"   maxlength="9"  id="ub04id85" value=""  title="41b. VALUE AMOUNT"  name="ub04Block_85"/>
1065 <input type="text"   maxlength="2"  id="ub04id86" value=""  title="39c. VALUE CODE"  name="ub04Block_86"/>
1066 <input type="text"   maxlength="9"  id="ub04id87" value=""  title="39c. VALUE AMOUNT"  name="ub04Block_87"/>
1067 <input type="text"   maxlength="2"  id="ub04id88" value=""  title="40c. VALUE CODE"  name="ub04Block_88"/>
1068 <input type="text"   maxlength="9"  id="ub04id89" value=""  title="40c. VALUE AMOUNT"  name="ub04Block_89"/>
1069 <input type="text"   maxlength="2"  id="ub04id90" value=""  title="41c. VALUE CODE"  name="ub04Block_90"/>
1070 <input type="text"   maxlength="9"  id="ub04id91" value=""  title="41c. VALUE AMOUNT"  name="ub04Block_91"/>
1071 <input type="text"   maxlength="2"  id="ub04id92" value=""  title="39d. VALUE CODE"  name="ub04Block_92"/>
1072 <input type="text"   maxlength="9"  id="ub04id93" value=""  title="39d. VALUE AMOUNT"  name="ub04Block_93"/>
1073 <input type="text"   maxlength="2"  id="ub04id94" value=""  title="40d. VALUE CODE"  name="ub04Block_94"/>
1074 <input type="text"   maxlength="9"  id="ub04id95" value=""  title="40d. VALUE AMOUNT"  name="ub04Block_95"/>
1075 <input type="text"   maxlength="2"  id="ub04id96" value=""  title="41d. VALUE CODE"  name="ub04Block_96"/>
1076 <input type="text"   maxlength="9"  id="ub04id97" value=""  title="41d. VALUE AMOUNT"  name="ub04Block_97"/>
1077 <textarea   id="ub04id98"  title="38. RESPONSIBLE PARTY NAME AND ADDRESS"  name="ub04Block_73"></textarea>
1078 <input type="text" class="revcode" maxlength="4"  id="ub04id99" value=""   title="42. REVENUE CODE, Line 1"  name="ub04Block_98"/>
1079 <input type="text"   maxlength="25"  id="ub04id100" value="" title="43. REVENUE DESCRIPTION, Line 1"  name="ub04Block_99"/>
1080 <input type="text"   maxlength="24"  id="ub04id101" value="" title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 1"  name="ub04Block_100"/>
1081 <input type="text"   maxlength="10"  id="ub04id102" value=""  title="45. SERVICE DATE, Line 1"  name="ub04Block_101"/>
1082 <input type="text"   maxlength="7"  id="ub04id103" value=""  title="46. SERVICE UNITS, Line 1"  name="ub04Block_102"/>
1083 <input type="text"   maxlength="9"  id="ub04id104" value=""  title="47. TOTAL CHARGES, Line 1"  name="ub04Block_103"/>
1084 <input type="text"   maxlength="9"  id="ub04id105" value=""  title="48. NON-COVERED CHARGES, Line 1"  name="ub04Block_104"/>
1085 <input type="text" disabled  maxlength="2"  id="ub04id106" value=""  title="49. RESERVED, Line 1"  name="ub04Block_105"/>
1086 <input type="text" class="revcode" maxlength="4"  id="ub04id107" value=""  title="42. REVENUE CODE, Line 2"  name="ub04Block_106"/>
1087 <input type="text"   maxlength="25"  id="ub04id108" value=""  title="43. REVENUE DESCRIPTION, Line 2"  name="ub04Block_107"/>
1088 <input type="text"   maxlength="24"  id="ub04id109" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 2"  name="ub04Block_108"/>
1089 <input type="text"   maxlength="10"  id="ub04id110" value=""  title="45. SERVICE DATE, Line 2"  name="ub04Block_109"/>
1090 <input type="text"   maxlength="7"  id="ub04id111" value=""  title="46. SERVICE UNITS, Line 2"  name="ub04Block_110"/>
1091 <input type="text"   maxlength="9"  id="ub04id112" value=""  title="47. TOTAL CHARGES, Line 2"  name="ub04Block_111"/>
1092 <input type="text"   maxlength="9"  id="ub04id113" value=""  title="48. NON-COVERED CHARGES, Line 2"  name="ub04Block_112"/>
1093 <input type="text" disabled  maxlength="2"  id="ub04id114" value=""  title="49. RESERVED, Line 2"  name="ub04Block_113"/>
1094 <input type="text"   maxlength="4"  id="ub04id115" value=""  title="42. REVENUE CODE, Line 3"  name="ub04Block_114"/>
1095 <input type="text"   maxlength="25"  id="ub04id116" value=""  title="43. REVENUE DESCRIPTION, Line 3"  name="ub04Block_115"/>
1096 <input type="text"   maxlength="24"  id="ub04id117" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 3"  name="ub04Block_116"/>
1097 <input type="text" class="revcode" maxlength="10"  id="ub04id118" value=""  title="45. SERVICE DATE, Line 3"  name="ub04Block_117"/>
1098 <input type="text"   maxlength="7"  id="ub04id119" value=""  title="46. SERVICE UNITS, Line 3"  name="ub04Block_118"/>
1099 <input type="text"   maxlength="9"  id="ub04id120" value=""  title="47. TOTAL CHARGES, Line 3"  name="ub04Block_119"/>
1100 <input type="text"   maxlength="9"  id="ub04id121" value=""  title="48. NON-COVERED CHARGES, Line 3"  name="ub04Block_120"/>
1101 <input type="text"  disabled maxlength="2"  id="ub04id122" value=""  title="49. RESERVED, Line 3"  name="ub04Block_121"/>
1102 <input type="text"   maxlength="4"  id="ub04id123" value=""  title="42. REVENUE CODE, Line 4"  name="ub04Block_122"/>
1103 <input type="text"   maxlength="25"  id="ub04id124" value=""  title="43. REVENUE DESCRIPTION, Line 4"  name="ub04Block_123"/>
1104 <input type="text"   maxlength="24"  id="ub04id125" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 4"  name="ub04Block_124"/>
1105 <input type="text"   maxlength="10"  id="ub04id126" value=""  title="45. SERVICE DATE, Line 4"  name="ub04Block_125"/>
1106 <input type="text"   maxlength="7"  id="ub04id127" value=""  title="46. SERVICE UNITS, Line 4"  name="ub04Block_126"/>
1107 <input type="text"   maxlength="9"  id="ub04id128" value=""  title="47. TOTAL CHARGES, Line 4"  name="ub04Block_127"/>
1108 <input type="text"   maxlength="9"  id="ub04id129" value=""  title="48. NON-COVERED CHARGES, Line 4"  name="ub04Block_128"/>
1109 <input type="text" disabled  maxlength="2"  id="ub04id130" value=""  title="49. RESERVED, Line 4"  name="ub04Block_129"/>
1110 <input type="text"   maxlength="4"  id="ub04id131" value=""  title="42. REVENUE CODE, Line 5"  name="ub04Block_130"/>
1111 <input type="text"   maxlength="25"  id="ub04id132" value=""  title="43. REVENUE DESCRIPTION, Line 5"  name="ub04Block_131"/>
1112 <input type="text"   maxlength="24"  id="ub04id133" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 5"  name="ub04Block_132"/>
1113 <input type="text"   maxlength="10"  id="ub04id134" value=""  title="45. SERVICE DATE, Line 5"  name="ub04Block_133"/>
1114 <input type="text"   maxlength="7"  id="ub04id135" value=""  title="46. SERVICE UNITS, Line 5"  name="ub04Block_134"/>
1115 <input type="text"   maxlength="9"  id="ub04id136" value=""  title="47. TOTAL CHARGES, Line 5"  name="ub04Block_135"/>
1116 <input type="text"   maxlength="9"  id="ub04id137" value=""  title="48. NON-COVERED CHARGES, Line 5"  name="ub04Block_136"/>
1117 <input type="text" disabled  maxlength="2"  id="ub04id138" value=""  title="49. RESERVED, Line 5"  name="ub04Block_137"/>
1118 <input type="text"   maxlength="4"  id="ub04id139" value=""  title="42. REVENUE CODE, Line 6"  name="ub04Block_138"/>
1119 <input type="text"   maxlength="25"  id="ub04id140" value=""  title="43. REVENUE DESCRIPTION, Line 6"  name="ub04Block_139"/>
1120 <input type="text"   maxlength="24"  id="ub04id141" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 6"  name="ub04Block_140"/>
1121 <input type="text"   maxlength="10"  id="ub04id142" value=""  title="45. SERVICE DATE, Line 6"  name="ub04Block_141"/>
1122 <input type="text"   maxlength="7"  id="ub04id143" value=""  title="46. SERVICE UNITS, Line 6"  name="ub04Block_142"/>
1123 <input type="text"   maxlength="9"  id="ub04id144" value=""  title="47. TOTAL CHARGES, Line 6"  name="ub04Block_143"/>
1124 <input type="text"   maxlength="9"  id="ub04id145" value=""  title="48. NON-COVERED CHARGES, Line 6"  name="ub04Block_144"/>
1125 <input type="text" disabled  maxlength="2"  id="ub04id146" value=""  title="49. RESERVED, Line 6"  name="ub04Block_145"/>
1126 <input type="text"   maxlength="4"  id="ub04id147" value=""  title="42. REVENUE CODE, Line 7"  name="ub04Block_146"/>
1127 <input type="text"   maxlength="25"  id="ub04id148" value=""  title="43. REVENUE DESCRIPTION, Line 7"  name="ub04Block_147"/>
1128 <input type="text"   maxlength="24"  id="ub04id149" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 7"  name="ub04Block_148"/>
1129 <input type="text"   maxlength="10"  id="ub04id150" value=""  title="45. SERVICE DATE, Line 7"  name="ub04Block_149"/>
1130 <input type="text"   maxlength="7"  id="ub04id151" value=""  title="46. SERVICE UNITS, Line 7"  name="ub04Block_150"/>
1131 <input type="text"   maxlength="9"  id="ub04id152" value=""  title="47. TOTAL CHARGES, Line 7"  name="ub04Block_151"/>
1132 <input type="text"   maxlength="9"  id="ub04id153" value=""  title="48. NON-COVERED CHARGES, Line 7"  name="ub04Block_152"/>
1133 <input type="text" disabled  maxlength="2"  id="ub04id154" value=""  title="49. RESERVED, Line 7"  name="ub04Block_153"/>
1134 <input type="text"   maxlength="4"  id="ub04id155" value=""  title="42. REVENUE CODE, Line 8"  name="ub04Block_154"/>
1135 <input type="text"   maxlength="25"  id="ub04id156" value=""  title="43. REVENUE DESCRIPTION, Line 8"  name="ub04Block_155"/>
1136 <input type="text"   maxlength="24"  id="ub04id157" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 8"  name="ub04Block_156"/>
1137 <input type="text"   maxlength="10"  id="ub04id158" value=""  title="45. SERVICE DATE, Line 8"  name="ub04Block_157"/>
1138 <input type="text"   maxlength="7"  id="ub04id159" value=""  title="46. SERVICE UNITS, Line 8"  name="ub04Block_158"/>
1139 <input type="text"   maxlength="9"  id="ub04id160" value=""  title="47. TOTAL CHARGES, Line 8"  name="ub04Block_159"/>
1140 <input type="text"   maxlength="9"  id="ub04id161" value=""  title="48. NON-COVERED CHARGES, Line 8"  name="ub04Block_160"/>
1141 <input type="text"   maxlength="2"  id="ub04id162" value=""  title="49. RESERVED, Line 8"  name="ub04Block_161"/>
1142 <input type="text"   maxlength="4"  id="ub04id163" value=""  title="42. REVENUE CODE, Line 9"  name="ub04Block_162"/>
1143 <input type="text"   maxlength="25"  id="ub04id164" value=""  title="43. REVENUE DESCRIPTION, Line 9"  name="ub04Block_163"/>
1144 <input type="text"   maxlength="24"  id="ub04id165" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 9"  name="ub04Block_164"/>
1145 <input type="text"   maxlength="10"  id="ub04id166" value=""  title="45. SERVICE DATE, Line 9"  name="ub04Block_165"/>
1146 <input type="text"   maxlength="7"  id="ub04id167" value=""  title="46. SERVICE UNITS, Line 9"  name="ub04Block_166"/>
1147 <input type="text"   maxlength="9"  id="ub04id168" value=""  title="47. TOTAL CHARGES, Line 9"  name="ub04Block_167"/>
1148 <input type="text"   maxlength="9"  id="ub04id169" value=""  title="48. NON-COVERED CHARGES, Line 9"  name="ub04Block_168"/>
1149 <input type="text" disabled  maxlength="2"  id="ub04id170" value=""  title="49. RESERVED, Line 9"  name="ub04Block_169"/>
1150 <input type="text"   maxlength="4"  id="ub04id171" value=""  title="42. REVENUE CODE, Line 10"  name="ub04Block_170"/>
1151 <input type="text"   maxlength="25"  id="ub04id172" value=""  title="43. REVENUE DESCRIPTION, Line 10"  name="ub04Block_171"/>
1152 <input type="text"   maxlength="24"  id="ub04id173" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 10"  name="ub04Block_172"/>
1153 <input type="text"   maxlength="10"  id="ub04id174" value=""  title="45. SERVICE DATE, Line 10"  name="ub04Block_173"/>
1154 <input type="text"   maxlength="7"  id="ub04id175" value=""  title="46. SERVICE UNITS, Line 10"  name="ub04Block_174"/>
1155 <input type="text"   maxlength="9"  id="ub04id176" value=""  title="47. TOTAL CHARGES, Line 10"  name="ub04Block_175"/>
1156 <input type="text"   maxlength="9"  id="ub04id177" value=""  title="48. NON-COVERED CHARGES, Line 10"  name="ub04Block_176"/>
1157 <input type="text"  disabled maxlength="2"  id="ub04id178" value=""  title="49. RESERVED, Line 10"  name="ub04Block_177"/>
1158 <input type="text"   maxlength="4"  id="ub04id179" value=""  title="42. REVENUE CODE, Line 11"  name="ub04Block_178"/>
1159 <input type="text"   maxlength="25"  id="ub04id180" value=""  title="43. REVENUE DESCRIPTION, Line 11"  name="ub04Block_179"/>
1160 <input type="text"   maxlength="24"  id="ub04id181" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 11"  name="ub04Block_180"/>
1161 <input type="text"   maxlength="10"  id="ub04id182" value=""  title="45. SERVICE DATE, Line 11"  name="ub04Block_181"/>
1162 <input type="text"   maxlength="7"  id="ub04id183" value=""  title="46. SERVICE UNITS, Line 11"  name="ub04Block_182"/>
1163 <input type="text"   maxlength="9"  id="ub04id184" value=""  title="47. TOTAL CHARGES, Line 11"  name="ub04Block_183"/>
1164 <input type="text"   maxlength="9"  id="ub04id185" value=""  title="48. NON-COVERED CHARGES, Line 11"  name="ub04Block_184"/>
1165 <input type="text" disabled  maxlength="2"  id="ub04id186" value=""  title="49. RESERVED, Line 11"  name="ub04Block_185"/>
1166 <input type="text"   maxlength="4"  id="ub04id187" value=""  title="42. REVENUE CODE, Line 12"  name="ub04Block_186"/>
1167 <input type="text"   maxlength="25"  id="ub04id188" value=""  title="43. REVENUE DESCRIPTION, Line 12"  name="ub04Block_187"/>
1168 <input type="text"   maxlength="24"  id="ub04id189" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 12"  name="ub04Block_188"/>
1169 <input type="text"   maxlength="10"  id="ub04id190" value=""  title="45. SERVICE DATE, Line 12"  name="ub04Block_189"/>
1170 <input type="text"   maxlength="7"  id="ub04id191" value=""  title="46. SERVICE UNITS, Line 12"  name="ub04Block_190"/>
1171 <input type="text"   maxlength="9"  id="ub04id192" value=""  title="47. TOTAL CHARGES, Line 12"  name="ub04Block_191"/>
1172 <input type="text"   maxlength="9"  id="ub04id193" value=""  title="48. NON-COVERED CHARGES, Line 12"  name="ub04Block_192"/>
1173 <input type="text" disabled  maxlength="2"  id="ub04id194" value=""  title="49. RESERVED, Line 12"  name="ub04Block_193"/>
1174 <input type="text"   maxlength="4"  id="ub04id195" value=""  title="42. REVENUE CODE, Line 13"  name="ub04Block_194"/>
1175 <input type="text"   maxlength="25"  id="ub04id196" value=""  title="43. REVENUE DESCRIPTION, Line 13"  name="ub04Block_195"/>
1176 <input type="text"   maxlength="24"  id="ub04id197" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 13"  name="ub04Block_196"/>
1177 <input type="text"   maxlength="10"  id="ub04id198" value=""  title="45. SERVICE DATE, Line 13"  name="ub04Block_197"/>
1178 <input type="text"   maxlength="7"  id="ub04id199" value=""  title="46. SERVICE UNITS, Line 13"  name="ub04Block_198"/>
1179 <input type="text"   maxlength="9"  id="ub04id200" value=""  title="47. TOTAL CHARGES, Line 13"  name="ub04Block_199"/>
1180 <input type="text"   maxlength="9"  id="ub04id201" value=""  title="48. NON-COVERED CHARGES, Line 13"  name="ub04Block_200"/>
1181 <input type="text" disabled  maxlength="2"  id="ub04id202" value=""  title="49. RESERVED, Line 13"  name="ub04Block_201"/>
1182 <input type="text"   maxlength="4"  id="ub04id203" value=""  title="42. REVENUE CODE, Line 14"  name="ub04Block_202"/>
1183 <input type="text"   maxlength="25"  id="ub04id204" value=""  title="43. REVENUE DESCRIPTION, Line 14"  name="ub04Block_203"/>
1184 <input type="text"   maxlength="24"  id="ub04id205" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 14"  name="ub04Block_204"/>
1185 <input type="text"   maxlength="10"  id="ub04id206" value=""  title="45. SERVICE DATE, Line 14"  name="ub04Block_205"/>
1186 <input type="text"   maxlength="7"  id="ub04id207" value=""  title="46. SERVICE UNITS, Line 14"  name="ub04Block_206"/>
1187 <input type="text"   maxlength="9"  id="ub04id208" value=""  title="47. TOTAL CHARGES, Line 14"  name="ub04Block_207"/>
1188 <input type="text"   maxlength="9"  id="ub04id209" value=""  title="48. NON-COVERED CHARGES, Line 14"  name="ub04Block_208"/>
1189 <input type="text"  disabled maxlength="2"  id="ub04id210" value=""  title="49. RESERVED, Line 14"  name="ub04Block_209"/>
1190 <input type="text"   maxlength="4"  id="ub04id211" value=""  title="42. REVENUE CODE, Line 15"  name="ub04Block_210"/>
1191 <input type="text"   maxlength="25"  id="ub04id212" value=""  title="43. REVENUE DESCRIPTION, Line 15"  name="ub04Block_211"/>
1192 <input type="text"   maxlength="24"  id="ub04id213" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 15"  name="ub04Block_212"/>
1193 <input type="text"   maxlength="10"  id="ub04id214" value=""  title="45. SERVICE DATE, Line 15"  name="ub04Block_213"/>
1194 <input type="text"   maxlength="7"  id="ub04id215" value=""  title="46. SERVICE UNITS, Line 15"  name="ub04Block_214"/>
1195 <input type="text"   maxlength="9"  id="ub04id216" value=""  title="47. TOTAL CHARGES, Line 15"  name="ub04Block_215"/>
1196 <input type="text"   maxlength="9"  id="ub04id217" value=""  title="48. NON-COVERED CHARGES, Line 15"  name="ub04Block_216"/>
1197 <input type="text" disabled  maxlength="2"  id="ub04id218" value=""  title="49. RESERVED, Line 15"  name="ub04Block_217"/>
1198 <input type="text"   maxlength="4"  id="ub04id219" value=""  title="42. REVENUE CODE, Line 16"  name="ub04Block_218"/>
1199 <input type="text"   maxlength="25"  id="ub04id220" value=""  title="43. REVENUE DESCRIPTION, Line 16"  name="ub04Block_219"/>
1200 <input type="text"   maxlength="24"  id="ub04id221" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 16"  name="ub04Block_220"/>
1201 <input type="text"   maxlength="10"  id="ub04id222" value=""  title="45. SERVICE DATE, Line 16"  name="ub04Block_221"/>
1202 <input type="text"   maxlength="7"  id="ub04id223" value=""  title="46. SERVICE UNITS, Line 16"  name="ub04Block_222"/>
1203 <input type="text"   maxlength="9"  id="ub04id224" value=""  title="47. TOTAL CHARGES, Line 16"  name="ub04Block_223"/>
1204 <input type="text"   maxlength="9"  id="ub04id225" value=""  title="48. NON-COVERED CHARGES, Line 16"  name="ub04Block_224"/>
1205 <input type="text" disabled  maxlength="2"  id="ub04id226" value=""  title="49. RESERVED, Line 16"  name="ub04Block_225"/>
1206 <input type="text"   maxlength="4"  id="ub04id227" value=""  title="42. REVENUE CODE, Line 17"  name="ub04Block_226"/>
1207 <input type="text"   maxlength="25"  id="ub04id228" value=""  title="43. REVENUE DESCRIPTION, Line 17"  name="ub04Block_227"/>
1208 <input type="text"   maxlength="24"  id="ub04id229" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 17"  name="ub04Block_228"/>
1209 <input type="text"   maxlength="10"  id="ub04id230" value=""  title="45. SERVICE DATE, Line 17"  name="ub04Block_229"/>
1210 <input type="text"   maxlength="7"  id="ub04id231" value=""  title="46. SERVICE UNITS, Line 17"  name="ub04Block_230"/>
1211 <input type="text"   maxlength="9"  id="ub04id232" value=""  title="47. TOTAL CHARGES, Line 17"  name="ub04Block_231"/>
1212 <input type="text"   maxlength="9"  id="ub04id233" value=""  title="48. NON-COVERED CHARGES, Line 17"  name="ub04Block_232"/>
1213 <input type="text" disabled  maxlength="2"  id="ub04id234" value=""  title="49. RESERVED, Line 17"  name="ub04Block_233"/>
1214 <input type="text"   maxlength="4"  id="ub04id235" value=""  title="42. REVENUE CODE, Line 18"  name="ub04Block_234"/>
1215 <input type="text"   maxlength="25"  id="ub04id236" value=""  title="43. REVENUE DESCRIPTION, Line 18"  name="ub04Block_235"/>
1216 <input type="text"   maxlength="24"  id="ub04id237" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 18"  name="ub04Block_236"/>
1217 <input type="text"   maxlength="10"  id="ub04id238" value=""  title="45. SERVICE DATE, Line 18"  name="ub04Block_237"/>
1218 <input type="text"   maxlength="7"  id="ub04id239" value=""  title="46. SERVICE UNITS, Line 18"  name="ub04Block_238"/>
1219 <input type="text"   maxlength="9"  id="ub04id240" value=""  title="47. TOTAL CHARGES, Line 18"  name="ub04Block_239"/>
1220 <input type="text"   maxlength="9"  id="ub04id241" value=""  title="48. NON-COVERED CHARGES, Line 18"  name="ub04Block_240"/>
1221 <input type="text" disabled  maxlength="2"  id="ub04id242" value=""  title="49. RESERVED, Line 18"  name="ub04Block_241"/>
1222 <input type="text"   maxlength="4"  id="ub04id243" value=""  title="42. REVENUE CODE, Line 19"  name="ub04Block_242"/>
1223 <input type="text"   maxlength="25"  id="ub04id244" value=""  title="43. REVENUE DESCRIPTION, Line 19"  name="ub04Block_243"/>
1224 <input type="text"   maxlength="24"  id="ub04id245" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 19"  name="ub04Block_244"/>
1225 <input type="text"   maxlength="10"  id="ub04id246" value=""  title="45. SERVICE DATE, Line 19"  name="ub04Block_245"/>
1226 <input type="text"   maxlength="7"  id="ub04id247" value=""  title="46. SERVICE UNITS, Line 19"  name="ub04Block_246"/>
1227 <input type="text"   maxlength="9"  id="ub04id248" value=""  title="47. TOTAL CHARGES, Line 19"  name="ub04Block_247"/>
1228 <input type="text"   maxlength="9"  id="ub04id249" value=""  title="48. NON-COVERED CHARGES, Line 19"  name="ub04Block_248"/>
1229 <input type="text" disabled  maxlength="2"  id="ub04id250" value=""  title="49. RESERVED, Line 19"  name="ub04Block_249"/>
1230 <input type="text"   maxlength="4"  id="ub04id251" value=""  title="42. REVENUE CODE, Line 20"  name="ub04Block_250"/>
1231 <input type="text"   maxlength="25"  id="ub04id252" value=""  title="43. REVENUE DESCRIPTION, Line 20"  name="ub04Block_251"/>
1232 <input type="text"   maxlength="24"  id="ub04id253" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 20"  name="ub04Block_252"/>
1233 <input type="text"   maxlength="10"  id="ub04id254" value=""  title="45. SERVICE DATE, Line 20"  name="ub04Block_253"/>
1234 <input type="text"   maxlength="7"  id="ub04id255" value=""  title="46. SERVICE UNITS, Line 20"  name="ub04Block_254"/>
1235 <input type="text"   maxlength="9"  id="ub04id256" value=""  title="47. TOTAL CHARGES, Line 20"  name="ub04Block_255"/>
1236 <input type="text"   maxlength="9"  id="ub04id257" value=""  title="48. NON-COVERED CHARGES, Line 20"  name="ub04Block_256"/>
1237 <input type="text" disabled  maxlength="2"  id="ub04id258" value=""  title="49. RESERVED, Line 20"  name="ub04Block_257"/>
1238 <input type="text"   maxlength="4"  id="ub04id259" value=""  title="42. REVENUE CODE, Line 21"  name="ub04Block_258"/>
1239 <input type="text"   maxlength="25"  id="ub04id260" value=""  title="43. REVENUE DESCRIPTION, Line 21"  name="ub04Block_259"/>
1240 <input type="text"   maxlength="24"  id="ub04id261" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 21"  name="ub04Block_260"/>
1241 <input type="text"   maxlength="10"  id="ub04id262" value=""  title="45. SERVICE DATE, Line 21"  name="ub04Block_261"/>
1242 <input type="text"   maxlength="7"  id="ub04id263" value=""  title="46. SERVICE UNITS, Line 21"  name="ub04Block_262"/>
1243 <input type="text"   maxlength="9"  id="ub04id264" value=""  title="47. TOTAL CHARGES, Line 21"  name="ub04Block_263"/>
1244 <input type="text"   maxlength="9"  id="ub04id265" value=""  title="48. NON-COVERED CHARGES, Line 21"  name="ub04Block_264"/>
1245 <input type="text" disabled  maxlength="2"  id="ub04id266" value=""  title="49. RESERVED, Line 21"  name="ub04Block_265"/>
1246 <input type="text"   maxlength="4"  id="ub04id267" value=""  title="42. REVENUE CODE, Line 22"  name="ub04Block_266"/>
1247 <input type="text"   maxlength="25"  id="ub04id268" value=""  title="43. REVENUE DESCRIPTION, Line 22"  name="ub04Block_267"/>
1248 <input type="text"   maxlength="24"  id="ub04id269" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 22"  name="ub04Block_268"/>
1249 <input type="text"   maxlength="10"  id="ub04id270" value=""  title="45. SERVICE DATE, Line 22"  name="ub04Block_269"/>
1250 <input type="text"   maxlength="7"  id="ub04id271" value=""  title="46. SERVICE UNITS, Line 22"  name="ub04Block_270"/>
1251 <input type="text"   maxlength="9"  id="ub04id272" value=""  title="47. TOTAL CHARGES, Line 22"  name="ub04Block_271"/>
1252 <input type="text"   maxlength="9"  id="ub04id273" value=""  title="48. NON-COVERED CHARGES, Line 22"  name="ub04Block_272"/>
1253 <input type="text" disabled  maxlength="2"  id="ub04id274" value=""  title="49. RESERVED, Line 22"  name="ub04Block_273"/>
1254 <input type="text"    id="ub04id275" value=""  title="42. REVENUE CODE, Line 23"  name="ub04Block_274"/>
1255 <input type="text"   maxlength="3"  id="ub04id276" value=""  title="43. CLAIM PAGE NUMBER"  name="ub04Block_275"/>
1256 <input type="text"   maxlength="3"  id="ub04id277" value=""  title="43. TOTAL NUMBER OF CLAIM PAGES"  name="ub04Block_276"/>
1257 <input type="text"    id="ub04id278" value=""  title="45. CREATION DATE, Line 23"  name="ub04Block_277"/>
1258 <input type="text"    id="ub04id279" value=""  title="47. TOTAL OF TOTAL CHARGES, Line 23"  name="ub04Block_278"/>
1259 <input type="text"    id="ub04id280" value=""  title="48. TOTAL OF NON-COVERED CHARGES, Line 23"  name="ub04Block_279"/>
1260 <input type="text" disabled id="ub04id281" value=""  title="49. RESERVED, Line 23"  name="ub04Block_280"/>
1261 <input type="text"   maxlength="10"  id="ub04id282" value="" title="56. NATIONAL PROVIDER IDENTIFIER - BILLING PROVIDER"  name="ub04Block_299"/>
1262 <input type="text"   maxlength="23"  id="ub04id283" value="" title="50a. PRIMARY PAYER NAME"  name="ub04Block_281"/>
1263 <input type="text"   maxlength="15"  id="ub04id284" value="" title="51a. PRIMARY PAYER HEALTH PLAN ID"  name="ub04Block_282"/>
1264 <input type="text"   maxlength="1"  id="ub04id285" value="" title="52a. RELEASE OF INFORMATION CERTIFICATION INDICATOR, PRIMARY PAYER"  name="ub04Block_283"/>
1265 <input type="text"   maxlength="1"  id="ub04id286" value="" title="53a. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, PRIMARY PAYER"  name="ub04Block_284"/>
1266 <input type="text"   maxlength="10"  id="ub04id287" value="" title="54a. PRIMARY PAYER PRIOR PAYMENTS"  name="ub04Block_285"/>
1267 <input type="text"   maxlength="10"  id="ub04id288" value="" title="55a. PRIMARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_286"/>
1268 <input type="text"    id="ub04id289" value=""  title="57a. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_300"/>
1269 <input type="text"   maxlength="23"  id="ub04id290" value="" title="50b. SECONDARY PAYER NAME"  name="ub04Block_287"/>
1270 <input type="text"   maxlength="15"  id="ub04id291" value="" title="51b. SECONDARY PAYER HEALTH PLAN ID"  name="ub04Block_288"/>
1271 <input type="text"   maxlength="1"  id="ub04id292" value="" title="52b. RELEASE OF INFORMATION CERTIFICATION INDICATOR, SECONDARY PAYER"  name="ub04Block_289"/>
1272 <input type="text"   maxlength="1"  id="ub04id293" value="" title="53b. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, SECONDARY PAYER"  name="ub04Block_290"/>
1273 <input type="text"   maxlength="10"  id="ub04id294" value="" title="54b. SECONDARY PAYER PRIOR PAYMENTS"  name="ub04Block_291"/>
1274 <input type="text"   maxlength="10"  id="ub04id295" value="" title="55b. SECONDARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_292"/>
1275 <input type="text"    id="ub04id296" value="" title="57b. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_301"/>
1276 <input type="text"   maxlength="23"  id="ub04id297" value="" title="50c. TERTIARY PAYER NAME"  name="ub04Block_293"/>
1277 <input type="text"   maxlength="15"  id="ub04id298" value="" title="51c. TERTIARY PAYER HEALTH PLAN ID"  name="ub04Block_294"/>
1278 <input type="text"   maxlength="1"  id="ub04id299" value="" title="52c.RELEASE OF INFORMATION CERTIFICATION INDICATOR, TERTIARY PAYER"  name="ub04Block_295"/>
1279 <input type="text"   maxlength="1"  id="ub04id300" value="" title="53c. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, TERTIARY PAYER"  name="ub04Block_296"/>
1280 <input type="text"   maxlength="10"  id="ub04id301" value="" title="54c. TERTIARY PAYER PRIOR PAYMENTS"  name="ub04Block_297"/>
1281 <input type="text"   maxlength="10"  id="ub04id302" value="" title="55c. TERTIARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_298"/>
1282 <input type="text"    id="ub04id303" value="" title="57c. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_302"/>
1283 <input type="text"   maxlength="25"  id="ub04id304" value="" title="58a. INSURED'S NAME - PRIMARY PLAN"  name="ub04Block_303"/>
1284 <input type="text"   maxlength="2"  id="ub04id305" value="" title="59a. PATIENT'S RELATIONSHIP TO INSURED - PRIMARY PLAN"  name="ub04Block_304"/>
1285 <input type="text"   maxlength="20"  id="ub04id306" value="" title="60a. INSURED'S UNIQUE IDENTIFIER - PRIMARY PLAN"  name="ub04Block_305"/>
1286 <input type="text"   maxlength="14"  id="ub04id307" value="" title="61a. INSURED'S GROUP NAME - PRIMARY PLAN"  name="ub04Block_306"/>
1287 <input type="text"   maxlength="17"  id="ub04id308" value="" title="62a. INSURANCE GROUP NUMBER - PRIMARY PLAN"  name="ub04Block_307"/>
1288 <input type="text"   maxlength="25"  id="ub04id309" value="" title="58b. INSURED'S NAME - SECONDARY PLAN"  name="ub04Block_308"/>
1289 <input type="text"   maxlength="2"  id="ub04id310" value="" title="59b. PATIENT'S RELATIONSHIP TO INSURED - SECONDARY PLAN"  name="ub04Block_309"/>
1290 <input type="text"   maxlength="20"  id="ub04id311" value="" title="60b. INSURED'S UNIQUE IDENTIFIER - SECONDARY PLAN"  name="ub04Block_310"/>
1291 <input type="text"   maxlength="14"  id="ub04id312" value="" title="61b. INSURED'S GROUP NAME - SECONDARY PLAN"  name="ub04Block_311"/>
1292 <input type="text"   maxlength="17"  id="ub04id313" value="" title="62b. INSURANCE GROUP NUMBER - SECONDARY PLAN"  name="ub04Block_312"/>
1293 <input type="text"   maxlength="25"  id="ub04id314" value="" title="58c. INSURED'S NAME - TERTIARY PLAN"  name="ub04Block_313"/>
1294 <input type="text"   maxlength="2"  id="ub04id315" value="" title="59c. PATIENT'S RELATIONSHIP TO INSURED - TERTIARY PLAN"  name="ub04Block_314"/>
1295 <input type="text"   maxlength="20"  id="ub04id316" value="" title="60c. INSURED'S UNIQUE IDENTIFIER - TERTIARY PLAN"  name="ub04Block_315"/>
1296 <input type="text"   maxlength="14"  id="ub04id317" value="" title="61c. INSURED'S GROUP NAME - TERTIARY PLAN"  name="ub04Block_316"/>
1297 <input type="text"   maxlength="17"  id="ub04id318" value="" title="62c. INSURANCE GROUP NUMBER - TERTIARY PLAN"  name="ub04Block_317"/>
1298 <input type="text"   maxlength="30"  id="ub04id319" value="" title="63a. TREATMENT AUTHORIZATION CODES - PRIMARY PLAN"  name="ub04Block_318"/>
1299 <input type="text"   maxlength="26"  id="ub04id320" value="" title="64a. DOCUMENT CONTROL NUMBER (DCN) - PRIMARY PLAN"  name="ub04Block_319"/>
1300 <input type="text"   maxlength="25"  id="ub04id321" value="" title="65a. INSURED'S EMPLOYER NAME - PRIMARY PLAN"  name="ub04Block_320"/>
1301 <input type="text"   maxlength="30"  id="ub04id322" value="" title="63b. TREATMENT AUTHORIZATION CODES - SECONDARY PLAN"  name="ub04Block_321"/>
1302 <input type="text"   maxlength="26"  id="ub04id323" value="" title="64b. DOCUMENT CONTROL NUMBER (DCN) - SECONDARY PLAN"  name="ub04Block_322"/>
1303 <input type="text"   maxlength="25"  id="ub04id324" value="" title="65b. INSURED'S EMPLOYER NAME - SECONDARY PLAN"  name="ub04Block_323"/>
1304 <input type="text"   maxlength="30"  id="ub04id325" value="" title="63c. TREATMENT AUTHORIZATION CODES - TERTIARY PLAN"  name="ub04Block_324"/>
1305 <input type="text"   maxlength="26"  id="ub04id326" value="" title="64c. DOCUMENT CONTROL NUMBER (DCN) - TERTIARY PLAN"  name="ub04Block_325"/>
1306 <input type="text"   maxlength="25"  id="ub04id327" value="" title="65c. INSURED'S EMPLOYER NAME - TERTIARY PLAN"  name="ub04Block_326"/>
1307 <input type="text"   maxlength="7"  id="ub04id328" value="" title="67. PRINCIPAL DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_328"/>
1308 <input type="text"   maxlength="1"  id="ub04id329" value="" title="67. PRINCIPAL DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_329"/>
1309 <input type="text"   maxlength="7"  id="ub04id330" value="" title="67A. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_330"/>
1310 <input type="text"   maxlength="1"  id="ub04id331" value="" title="67A. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_331"/>
1311 <input type="text"   maxlength="7"  id="ub04id332" value="" title="67B. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_332"/>
1312 <input type="text"   maxlength="1"  id="ub04id333" value="" title="67B. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_333"/>
1313 <input type="text"   maxlength="7"  id="ub04id334" value="" title="67C. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_334"/>
1314 <input type="text"   maxlength="1"  id="ub04id335" value="" title="67C. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_335"/>
1315 <input type="text"   maxlength="7"  id="ub04id336" value="" title="67D. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_336"/>
1316 <input type="text"   maxlength="1"  id="ub04id337" value="" title="67D. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_337"/>
1317 <input type="text"   maxlength="7"  id="ub04id338" value="" title="67E. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_338"/>
1318 <input type="text"   maxlength="1"  id="ub04id339" value="" title="67E. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_339"/>
1319 <input type="text"   maxlength="7"  id="ub04id340" value="" title="67F. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_340"/>
1320 <input type="text"   maxlength="1"  id="ub04id341" value="" title="67F. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_341"/>
1321 <input type="text"   maxlength="7"  id="ub04id342" value="" title="67G. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_342"/>
1322 <input type="text"   maxlength="1"  id="ub04id343" value="" title="67G. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_343"/>
1323 <input type="text"   maxlength="7"  id="ub04id344" value="" title="67H. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_344"/>
1324 <input type="text"   maxlength="1"  id="ub04id345" value="" title="67H. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_345"/>
1325 <input type="text" disabled  maxlength="8"  id="ub04id346" value="" title="68. RESERVED"  name="ub04Block_364"/>
1326 <input type="text"   maxlength="1"  id="ub04id347" value="" title="66. DIAGNOSIS AND PROCEDURE CODE QUALIFIER (ICD VERSION INDICATOR)"  name="ub04Block_327"/>
1327 <input type="text"   maxlength="7"  id="ub04id348" value="" title="67I. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_346"/>
1328 <input type="text"   maxlength="1"  id="ub04id349" value="" title="67I. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_347"/>
1329 <input type="text"   maxlength="7"  id="ub04id350" value="" title="67J. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_348"/>
1330 <input type="text"   maxlength="1"  id="ub04id351" value="" title="67J. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_349"/>
1331 <input type="text"   maxlength="7"  id="ub04id352" value="" title="67K. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_350"/>
1332 <input type="text"   maxlength="1"  id="ub04id353" value="" title="67K. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_351"/>
1333 <input type="text"   maxlength="7"  id="ub04id354" value="" title="67L. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_352"/>
1334 <input type="text"   maxlength="1"  id="ub04id355" value="" title="67L. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_353"/>
1335 <input type="text"   maxlength="7"  id="ub04id356" value="" title="67M. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_354"/>
1336 <input type="text"   maxlength="1"  id="ub04id357" value="" title="67M. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_355"/>
1337 <input type="text"   maxlength="7"  id="ub04id358" value="" title="67N. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_356"/>
1338 <input type="text"   maxlength="1"  id="ub04id359" value="" title="67N. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_357"/>
1339 <input type="text"   maxlength="7"  id="ub04id360" value="" title="67O. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_358"/>
1340 <input type="text"   maxlength="1"  id="ub04id361" value="" title="67O. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_359"/>
1341 <input type="text"   maxlength="7"  id="ub04id362" value="" title="67P. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_360"/>
1342 <input type="text"   maxlength="7"  id="ub04id363" value="" title="67Q. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_362"/>
1343 <input type="text"   maxlength="1"  id="ub04id364" value="" title="67Q. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_363"/>
1344 <input type="text" disabled  maxlength="9"  id="ub04id365" value="" title="68. RESERVED"  name="ub04Block_365"/>
1345 <input type="text"   maxlength="1"  id="ub04id366" value="" title="67P. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_361"/>
1346 <input type="text"   maxlength="7"  id="ub04id367" value="" title="69. ADMITTING DIAGNOSIS CODE"  name="ub04Block_366"/>
1347 <input type="text"   maxlength="7"  id="ub04id368" value="" title="70a. PATIENT'S REASON FOR VISIT"  name="ub04Block_367"/>
1348 <input type="text"   maxlength="7"  id="ub04id369" value="" title="70b. PATIENT'S REASON FOR VISIT"  name="ub04Block_368"/>
1349 <input type="text"   maxlength="7"  id="ub04id370" value="" title="70c. PATIENT'S REASON FOR VISIT"  name="ub04Block_369"/>
1350 <input type="text"   maxlength="4"  id="ub04id371" value="" title="71. PROSPECTIVE PAYMENT SYSTEM (PPS) CODE"  name="ub04Block_370"/>
1351 <input type="text"   maxlength="7"  id="ub04id372" value="" title="72a. EXTERNAL CAUSE OF INJURY (ECI) CODE AND POA INDICATOR"  name="ub04Block_371"/>
1352 <input type="text"   maxlength="1"  id="ub04id373" value="" title="72a. EXTERNAL CAUSE OF INJURY (ECI) PRESENT ON ADMISSION INDICATOR "  name="ub04Block_372"/>
1353 <input type="text"   maxlength="7"  id="ub04id374" value="" title="72b. EXTERNAL CAUSE OF INJURY (ECI) CODE AND POA INDICATOR"  name="ub04Block_373"/>
1354 <input type="text"   maxlength="1"  id="ub04id375" value="" title="72b. EXTERNAL CAUSE OF INJURY (ECI) PRESENT ON ADMISSION INDICATOR "  name="ub04Block_374"/>
1355 <input type="text"   maxlength="7"  id="ub04id376" value="" title="72c. EXTERNAL CAUSE OF INJURY (ECI) CODE AND POA INDICATOR"  name="ub04Block_375"/>
1356 <input type="text"   maxlength="1"  id="ub04id377" value="" title="72c. EXTERNAL CAUSE OF INJURY (ECI) PRESENT ON ADMISSION INDICATOR "  name="ub04Block_376"/>
1357 <input type="text" disabled  maxlength="9"  id="ub04id378" value="" title="73. RESERVED"  name="ub04Block_377"/>
1358 <input type="text" class="user"  maxlength="11"  id="ub04id379" value="" title="76. ATTENDING PROVIDER NATIONAL PROVIDER IDENTIFIER"  name="ub04Block_391"/>
1359 <input type="text"   maxlength="2"  id="ub04id380" value="" title="76. ATTENDING PROVIDER SECONDARY IDENTIFIER QUALIFIER"  name="ub04Block_392"/>
1360 <input type="text"   maxlength="9"  id="ub04id381" value="" title="76. ATTENDING PROVIDER SECONDARY IDENTIFIER"  name="ub04Block_393"/>
1361 <input type="text"   maxlength="7"  id="ub04id382" value="" title="74. PRINCIPAL PROCEDURE CODE"  name="ub04Block_378"/>
1362 <input type="text"   maxlength="10"  id="ub04id383" value="" title="74. PRINCIPAL PROCEDURE DATE"  name="ub04Block_379"/>
1363 <input type="text"   maxlength="7"  id="ub04id384" value="" title="74a. OTHER PROCEDURE CODE"  name="ub04Block_380"/>
1364 <input type="text"   maxlength="10"  id="ub04id385" value="" title="74a. OTHER PROCEDURE DATE"  name="ub04Block_381"/>
1365 <input type="text"   maxlength="7"  id="ub04id386" value="" title="74b. OTHER PROCEDURE CODE"  name="ub04Block_382"/>
1366 <input type="text"   maxlength="10"  id="ub04id387" value="" title="74b. OTHER PROCEDURE DATE"  name="ub04Block_383"/>
1367 <input type="text"   maxlength="16"  id="ub04id388" value="" title="76. ATTENDING PROVIDER LAST NAME"  name="ub04Block_394"/>
1368 <input type="text"   maxlength="12"  id="ub04id389" value="" title="76. ATTENDING PROVIDER FIRST NAME"  name="ub04Block_395"/>
1369 <input type="text" class="user" maxlength="11"  id="ub04id390" value="" title="77. OPERATING PHYSICIAN NATIONAL PROVIDER IDENTIFIER"  name="ub04Block_396"/>
1370 <input type="text"   maxlength="2"  id="ub04id391" value="" title="77. OPERATING PHYSICIAN SECONDARY IDENTIFIER QUALIFIER"  name="ub04Block_397"/>
1371 <input type="text"   maxlength="9"  id="ub04id392" value="" title="77. OPERATING PHYSICIAN SECONDARY IDENTIFIER"  name="ub04Block_398"/>
1372 <input type="text"   maxlength="7"  id="ub04id393" value="" title="74c. OTHER PROCEDURE CODE"  name="ub04Block_384"/>
1373 <input type="text"   maxlength="10"  id="ub04id394" value="" title="74c. OTHER PROCEDURE DATE"  name="ub04Block_385"/>
1374 <input type="text"   maxlength="7"  id="ub04id395" value="" title="74d. OTHER PROCEDURE CODE"  name="ub04Block_386"/>
1375 <input type="text"   maxlength="10"  id="ub04id396" value="" title="74d. OTHER PROCEDURE DATE"  name="ub04Block_387"/>
1376 <input type="text"   maxlength="7"  id="ub04id397" value="" title="74e. OTHER PROCEDURE CODE"  name="ub04Block_388"/>
1377 <input type="text"   maxlength="10"  id="ub04id398" value="" title="74d. OTHER PROCEDURE DATE"  name="ub04Block_389"/>
1378 <textarea disabled maxlength="16"  id="ub04id399" title="75. RESERVED"  name="ub04Block_390"></textarea>
1379 <input type="text"   maxlength="16"  id="ub04id400" value="" title="77. OPERATING PHYSICIAN LAST NAME"  name="ub04Block_399"/>
1380 <input type="text"   maxlength="12"  id="ub04id401" value="" title="77. OPERATING PHYSICIAN FIRST NAME"  name="ub04Block_400"/>
1381 <input type="text"   maxlength="2"  id="ub04id402" value="" title="81a. CODE QUALIFIER"  name="ub04Block_417"/>
1382 <input type="text"   maxlength="10"  id="ub04id403" value="" title="81a. CODE"  name="ub04Block_421"/>
1383 <input type="text"   maxlength="12"  id="ub04id404" value="" title="81a. VALUE"  name="ub04Block_425"/>
1384 <input type="text"   maxlength="2"  id="ub04id405" value="" title="79. OTHER PROVIDER TYPE QUALIFIER"  name="ub04Block_401"/>
1385 <input type="text" class="user" maxlength="11"  id="ub04id406" value="" title="78. OTHER PROVIDER NATIONAL PROVIDER IDENTIFIER"  name="ub04Block_402"/>
1386 <input type="text"   maxlength="2"  id="ub04id407" value="" title="78. OTHER PROVIDER SECONDARY IDENTIFIER QUALIFIER"  name="ub04Block_403"/>
1387 <input type="text"   maxlength="9"  id="ub04id408" value="" title="78. OTHER PROVIDER SECONDARY IDENTIFIER"  name="ub04Block_404"/>
1388 <input type="text"   maxlength="19"  id="ub04id409" value="" title="80. REMARKS"  name="ub04Block_413"/>
1389 <input type="text"   maxlength="2"  id="ub04id410" value="" title="81b. CODE QUALIFIER"  name="ub04Block_418"/>
1390 <input type="text"   maxlength="10"  id="ub04id411" value="" title="81b. CODE"  name="ub04Block_422"/>
1391 <input type="text"   maxlength="12"  id="ub04id412" value="" title="81b. VALUE"  name="ub04Block_426"/>
1392 <input type="text"   maxlength="16"  id="ub04id413" value="" title="78. OTHER PROVIDER LAST NAME"  name="ub04Block_405"/>
1393 <input type="text"   maxlength="12"  id="ub04id414" value="" title="78. OTHER PROVIDER FIRST NAME"  name="ub04Block_406"/>
1394 <input type="text"   maxlength="24"  id="ub04id415" value="" title="80. REMARKS"  name="ub04Block_414"/>
1395 <input type="text"   maxlength="2"  id="ub04id416" value="" title="81c. CODE QUALIFIER"  name="ub04Block_419"/>
1396 <input type="text"   maxlength="10"  id="ub04id417" value="" title="81c. CODE"  name="ub04Block_423"/>
1397 <input type="text"   maxlength="12"  id="ub04id418" value="" title="81c. VALUE"  name="ub04Block_427"/>
1398 <input type="text"   maxlength="2"  id="ub04id419" value="" title="79. OTHER PROVIDER TYPE QUALIFIER"  name="ub04Block_407"/>
1399 <input type="text" class="user"  maxlength="11"  id="ub04id420" value="" title="79. OTHER PROVIDER NATIONAL PROVIDER IDENTIFIER"  name="ub04Block_408"/>
1400 <input type="text"   maxlength="9"  id="ub04id421" value="" title="79. OTHER PROVIDER SECONDARY IDENTIFIER"  name="ub04Block_410"/>
1401 <input type="text"   maxlength="2"  id="ub04id422" value="" title="79. OTHER PROVIDER SECONDARY IDENTIFIER QUALIFIER"  name="ub04Block_409"/>
1402 <input type="text"   maxlength="24"  id="ub04id423" value="" title="80. REMARKS"  name="ub04Block_415"/>
1403 <input type="text"   maxlength="2"  id="ub04id424" value="" title="81d. CODE QUALIFIER"  name="ub04Block_420"/>
1404 <input type="text"   maxlength="10"  id="ub04id425" value="" title="81d. CODE"  name="ub04Block_424"/>
1405 <input type="text"   maxlength="12"  id="ub04id426" value="" title="81d. VALUE"  name="ub04Block_428"/>
1406 <input type="text"   maxlength="16"  id="ub04id427" value="" title="79. OTHER PROVIDER LAST NAME"  name="ub04Block_411"/>
1407 <input type="text"   maxlength="12"  id="ub04id428" value="" title="79. OTHER PROVIDER FIRST NAME"  name="ub04Block_412"/>
1408 <input type="text"   maxlength="24"  id="ub04id429" value="" title="80. REMARKS"  name="ub04Block_416"/>
1409 </form>
1410 <!-- End Form Data -->
1411 </div>
1412 </div>
1413 </body>
1414 </html>