24. A. DATE(S) OF SERVICE |
B. PLACE OF SERVICE |
C. EMG |
D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) |
E. DIAGNOSIS POINTER |
F. $ CHARGES |
G. DAYS OR UNITS |
H. EPSDT Family Plan |
I. ID. QUAL. |
J. RENDERING PROVIDER ID. # |
FROM |
TO |
CPT/HCPCS |
MODIFIER |
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