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At all times. Anywhere Medical Center 111 ABC St Anywhere, CA 00001 Bill type 13X for Hospital outpatient 123 MAIN ST DOE, JOHN W ANYWHERE CATHETER DECLOTTING INJECTION, MMDDYY MMDDYY X 2 HCPCS code J2997 for Injection, recombinant, 1 mg XXX XX XXX XX Input number of units of administered (1 mg 1 unit) SA M Revenue code 0636 for Drugs requiring specific information 36593 J2997 PL E 0260 0636 CA CPT 1 code 36593 for Declotting b.

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Keywords relevant to Ub Claim Form Sample

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