RIC         1  3                                        C RECORD IDENTIFICATION CODE

FILEYR      4  2                                        C YY REFERENCE YEAR OF RECORD

BASEID      6  8  $BSIDFMT                              C UNIQUE IDENTIFICATION NUMBER

                              11,365             LOW-HIGH BASEID Count

EVNTNUM    14  4                                        C UNIQUE EVENT IDENTIFIER

OREVTYPE   18  2  $EVNTTYP                              C ORIGINAL REPORTED EVENT TYPE

                                   1
                              11,364                   DU DENTAL
                                   0                   ER EMERGENCY ROOM
                                   0                   IP INPATIENT
                                   0                   IU INSTITUTIONAL UTILIZATION
                                   0                   MP MEDICAL PROVIDER
                                   0                   OM OTHER MEDICAL EXPENSE
                                   0                   OP OUTPATIENT
                                   0                   PM PRESCRIBED MEDICINE
                                   0                   SD SEP BILLING DOCTOR
                                   0                   SL SEP BILLING LAB

CLAIMID    20  6                                        N CLAIM THIS SURVEY EVENT MATCHED TO

HMO        26  1  $HMO                                  C EVENT PROVIDED BY AN HMO?

                              10,014                    0 EVENT NOT PROV BY HMO
                               1,351                    1 EVENT PROVIDED BY HMO

EVBEGYY    27  2  EVYY                                  N EVENT BEGIN YEAR

                                   7                    . INAPPLICABLE
                                  27                   -8 DK
                              11,331                 1-99 YEAR

EVBEGMM    29  2  EVMM                                  N EVENT BEGIN MONTH

                                   7                    . INAPPLICABLE
                                  64                   -8 DK
                              11,294                 1-12 MONTH
                                   0                   95 STILL IN PROGRESS

EVBEGDD    31  2  EVDD                                  N EVENT BEGIN YEAR

                                   7                    . INAPPLICABLE
                                   1                   -9 NOT ASCERTAINED
                               1,324                   -8 DK
                                   3                   -7 REFUSED
                                   4                   -5 MULTIPLE VISITS THIS MONTH
                              10,026                 1-31 DAY OF MONTH

SOURCE     33  1  $SOURCE                               C SOURCE OF EVENT: SURVEY, CLAIM, OR BOTH?

                              11,312                    1 SURVEY ONLY
                                   1                    2 CLAIMS ONLY
                                  52                    3 BOTH SURVEY & CLAIMS

SITCODE    34  1  $SITCODE                              C COMMUNITY OR FACILITY SETTING?

                                   3                    B BOTH COMM & FACILITY
                              11,361                    C COMMUNITY
                                   0                    D DEEMED COMMUNITY
                                   1                    F FACILITY
                                   0                    G DEEMED FACILITY

AMTTOT     35  9                                        N TOTAL PAYMENT

IMPATOT    44  1  IMPFLAG                               N IMPUTATION FLAG: AMT TOTAL PAYMENT

                               8,695                    0 NOT IMPUTED
                               2,670                    1 IMPUTED

AMTCOV     45  9                                        N PORTION OF TOTAL PAY COV BY MEDICARE

AMTNCOV    54  9                                        N PORTION OF TOTAL PAY NOT COV BY MEDICARE

AMTCARE    63  9                                        N AMOUNT PAID BY MEDICARE

IMPSCARE   72  1  IMPFLAG                               N IMPUTATION FLAG: SOP MEDICARE

                              11,365                    0 NOT IMPUTED
                                   0                    1 IMPUTED

IMPACARE   73  1  IMPFLAG                               N IMPUTATION FLAG: AMT MEDICARE

                              11,365                    0 NOT IMPUTED
                                   0                    1 IMPUTED

AMTCAID    74  9                                        N AMOUNT PAID BY MEDICAID

IMPSCAID   83  1  IMPFLAG                               N IMPUTATION FLAG: SOP MEDICAID

                              11,360                    0 NOT IMPUTED
                                   5                    1 IMPUTED

IMPACAID   84  1  IMPFLAG                               N IMPUTATION FLAG: AMT MEDICAID

                              10,771                    0 NOT IMPUTED
                                 594                    1 IMPUTED

AMTHMOM    85  9                                        N AMOUNT PAID BY MEDICARE HMO

IMPSHMOM   94  1  IMPFLAG                               N IMPUTATION FLAG: SOP MEDICARE HMO

                              11,344                    0 NOT IMPUTED
                                  21                    1 IMPUTED

IMPAHMOM   95  1  IMPFLAG                               N IMPUTATION FLAG: AMT MEDICARE HMO

                              11,253                    0 NOT IMPUTED
                                 112                    1 IMPUTED

AMTHMOP    96  9                                        N AMOUNT PAID BY PRIVATE HMO

IMPSHMOP  105  1  IMPFLAG                               N IMPUTATION FLAG: SOP PRIVATE HMO

                              11,357                    0 NOT IMPUTED
                                   8                    1 IMPUTED

IMPAHMOP  106  1  IMPFLAG                               N IMPUTATION FLAG: AMT PRIVATE HMO

                              11,308                    0 NOT IMPUTED
                                  57                    1 IMPUTED

AMTVA     107  9                                        N AMOUNT PAID BY VETERANS ADM

IMPSVA    116  1  IMPFLAG                               N IMPUTATION FLAG: SOP VETERANS ADM

                              11,364                    0 NOT IMPUTED
                                   1                    1 IMPUTED

IMPAVA    117  1  IMPFLAG                               N IMPUTATION FLAG: AMT VETERANS ADM

                              11,246                    0 NOT IMPUTED
                                 119                    1 IMPUTED

AMTPRVE   118  9                                        N AMOUNT PAID BY PRIV INS (EMPLOYER SPONS)

IMPSPRVE  127  1  IMPFLAG                               N IMPUTATION FLAG: SOP PRIV INS-EMPLOYER

                              11,163                    0 NOT IMPUTED
                                 202                    1 IMPUTED

IMPAPRVE  128  1  IMPFLAG                               N IMPUTATION FLAG: AMT PRIV INS-EMPLOYER

                              10,880                    0 NOT IMPUTED
                                 485                    1 IMPUTED

AMTPRVI   129  9                                        N AMOUNT PAID BY PRIV INS (INDIV PURCH)

IMPSPRVI  138  1  IMPFLAG                               N IMPUTATION FLAG: SOP PRIV INS-INDIV PUR

                              11,313                    0 NOT IMPUTED
                                  52                    1 IMPUTED

IMPAPRVI  139  1  IMPFLAG                               N IMPUTATION FLAG: AMT PRIV INS-INDIV PUR

                              11,195                    0 NOT IMPUTED
                                 170                    1 IMPUTED

AMTPRVU   140  9                                        N AMOUNT PAID BY PRIV INS (UNKNOWN PURCH)

IMPSPRVU  149  1  IMPFLAG                               N IMPUTATION FLAG: SOP PRIV INS-UNKNOWN

                              11,365                    0 NOT IMPUTED
                                   0                    1 IMPUTED

IMPAPRVU  150  1  IMPFLAG                               N IMPUTATION FLAG: AMT PRIV INS-UNKNOWN

                              11,365                    0 NOT IMPUTED
                                   0                    1 IMPUTED

AMTOOP    151  9                                        N AMOUNT PAID BY PERSON/FAMILY

IMPSOOP   160  1  IMPFLAG                               N IMPUTATION FLAG: SOP PAID BY PERSON

                              10,808                    0 NOT IMPUTED
                                 557                    1 IMPUTED

IMPAOOP   161  1  IMPFLAG                               N IMPUTATION FLAG: AMT PAID BY PERSON

                              10,144                    0 NOT IMPUTED
                               1,221                    1 IMPUTED

AMTDISC   162  9                                        N AMOUNT OF UNCOLLECTED LIABILITIES

IMPSDISC  171  1  IMPFLAG                               N IMPUTATION FLAG: SOP OF UNCOLL LIAB

                              11,215                    0 NOT IMPUTED
                                 150                    1 IMPUTED

IMPADISC  172  1  IMPFLAG                               N IMPUTATION FLAG: AMT OF UNCOLL LIAB

                              10,885                    0 NOT IMPUTED
                                 480                    1 IMPUTED

AMTOTH    173  9                                        N AMOUNT PAID BY OTHER SOURCES

IMPSOTH   182  1  IMPFLAG                               N IMPUTATION FLAG: SOP OTHER SOURCES

                              11,356                    0 NOT IMPUTED
                                   9                    1 IMPUTED

IMPAOTH   183  1  IMPFLAG                               N IMPUTATION FLAG: AMT OTHER SOURCES

                              11,272                    0 NOT IMPUTED
                                  93                    1 IMPUTED

DVBRIDGE  184  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-BRIDGE

                                   1                    .
                                   9                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                               2,495                    1 YES
                               8,827                    2 NO

DVCLEAN   186  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-CLEANING

                                   1                    .
                                  11                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                               4,055                    1 YES
                               7,265                    2 NO

DVCROWN   188  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-CROWN

                                   1                    .
                                  11                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                                 862                    1 YES
                              10,458                    2 NO

DVEXAM    190  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-EXAMIN

                                   1                    .
                                  11                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                               3,798                    1 YES
                               7,522                    2 NO

DVEXTRAC  192  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-EXTRACT

                                   1                    .
                                  11                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                                 903                    1 YES
                              10,417                    2 NO

DVFILLNG  194  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-FILLING

                                   1                    .
                                  10                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                               1,880                    1 YES
                               9,441                    2 NO

DVORTHO   196  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-ORTHODON

                                   1                    .
                                  11                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                                 128                    1 YES
                              11,192                    2 NO

DVOTHER   198  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-OTHER

                                   1                    .
                                  10                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                                 723                    1 YES
                              10,598                    2 NO

DVRTCNAL  200  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-ROOT CANAL

                                   1                    .
                                  11                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                                 504                    1 YES
                              10,816                    2 NO

DVXRAYS   202  2  YESNO                                 N HAVE DONE DURING DENTAL VISIT-XRAYS

                                   1                    .
                                  12                   -9 NOT ASCERTAINED
                                  31                   -8 DK
                                   2                   -1 INAPPLICABLE
                               2,770                    1 YES
                               8,549                    2 NO

