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Sample CMS-1500 Claim Form

08-15-2012 11:35

Box 24 D is the area where you will report the quality data G-codes.

G-codes must be submitted with a line-item charge of "0" (zero). Dollar signs ($) or decimal points are not accepted. NOTE: The total charge for the claim cannot be zero.

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Sample CMS-1500 Claim Form   314K   1 version

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