E D. [ D PROCEDURES. SERVICES. OR SuPPLES {5.9lain Unusual Cirortoaroos) ENG , CPTRICPCS I MODIFIER E. mAGNOSIS POINTER F, 3 CHARGES G. O DARYS UNITS H. EPSDT F" Pie, L ID. DUAL .1 RENDERING PROVIDER ID 9 01 22 15 1 01 • 22 15 1 11 N ' 99205 25 A 500. 00 1 NPI 1932136231