Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
Reference Identification
String (AN)
Mandatory
1
80
1
Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
PS101 is provider identification number.
02
Monetary Amount
Decimal number (R)
Mandatory
1
18
1
Monetary amount
PS102 is cost of the purchased service.
03
State or Province Code
Identifier (ID)
Optional
2
2
1
Code specifying the Standard State/Province as defined by appropriate
government agency
PS103 is the state where the service is purchased.