<?xml version="1.0"?>
<ChargeBatch>
<FacilityID>5</FacilityID>
<FacilityName>Small Facility</FacilityName>
<OriginatingSystem>RFW</OriginatingSystem>
<BatchDate>12-01-2003</BatchDate>
<Transaction>
<PatientID>1304394</PatientID>
<MRN>333874</MRN>
<ChargeCode>85581</ChargeCode>
<ChargeDescription>bandaid</ChargeDescription>
<ServiceDate>11-25-2003</ServiceDate>
<Quantity>1</Quantity>
<UnitPrice>.56</UnitPrice>
<Cost>0</Cost>
<UnitOfMeasure>each</UnitOfMeasure>
<Category>16</Category>
<Visits>0</Visits>
<HCPCCode></HCPCCode>
<HcpcsModifier2></HcpcsModifier2>
<HcpcsModifier3></HcpcsModifier3>
<HcpcsModifier4></HcpcsModifier4>
</Transaction>
</ChargeBatch>