xyz789 23456789 insurer hospital1234 111-1111-1111111-1 800 174 626 MF2057 1 1245 01/01/2009 12:00 01/01/2010 15:003 2 Principal 012.13 01/01/2009 13:00 3 77057 1 313 clinician3456 CPT 77057 3342F CPT 01/01/2009 13:00 3 77052 1 313 clinician3456