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M Rebill PRESCRIPTION/SERVICE REFERENCE 1 Rx Billing NUMBER QUALIFIER PRESCRIPTION/SERVICE REFERENCE NUMBER PRODUCT/SERVICE ID QUALIFIER PRODUCT/SERVICE ID QUANTITY DISPENSED FILL NUMBER DAYS SUPPLY COMPOUND CODE DISPENSE AS WRITTEN (DAW)/PRODUCT SELECTION CODE DATE PRESCRIPTION WRITTEN NUMBER OF REFILLS AUTHORIZED PRESCRIPTION ORIGIN CODE SUBMISSION CLARIFICATION CODE Maximum count of 3. COUNT SUBMISSION CLARIFICATION CODE OTHER COVERAGE CODE Payer Usage O O R R R R O O O O O S O O O Re.

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