SV3 Dental Service

Code identifying the type/source of the descriptive number used in Product/Service ID (234).

Identifying number for a product or service.

Monetary amount.

Code identifying the type of facility where services were performed; the first position of the uniform bill type or place of service from health care financing administration claim form or place of treatment from the dental claim form

Reference number or identification number as defined for a particular Transaction Set, or as specified by the Reference Number Qualifier.

Code identifying the area of the tooth that was treated

Code identifying the dental quadrant of the mouth in which service is rendered

Code specifying the placement status for the dental work

Numeric value of quantity.

A free-form description to clarify the related data elements and their content.

Code indicating whether or not co-payment requirements were met on a line by line basis

Code indicating the type of agreement under which the provider is submitting this claim