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L Street or City, State, Zip claimant / vend Code claimant / vendor Facility: Red Server Patient: VA, Patient SSN (last 4 digits): 0000 patient identification Period: 04/21/2012 to 04/29/2012 Program: Authorized Claim ID: 1111 Claim Adj. Codes: CR-67* n ient identificatio pat ts): 0000 SSN (last 4 digi DOS Rev Code Prim Diag. Adm.Diag. QTY Billed Paid Adj. Codes es: CR.71* Claim Adj.Cod Claim ID: 1111 04/22/2012 0320 V54.09 V54.09 1 0.31 0.00 Paid 04/23/2012 0.

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  • CE-56003
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