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C. 80 68 CODE PRINCIPAL PROCEDURE OTHER DIAG. CODES 71 CODE OTHER PROCEDURE D 76 ADM. DIAG. CD. 77 E-CODE 82 ATTENDING PHYS. ID 83 OTHER PHYS. ID E a 84 REMARKS UB-92 HCFA-1450 85 PROVIDER REPRESENTATIVE x OCR/ORIGINAL 86 DATE I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

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