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UB-04

 All Claim Forms ship FREE Priority Mail (2-3 day) delivery. You will not be able to choose a different method in the cart.

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  1. Facility Type Codes

    Facility Type Codes

    Item

    FTC-F12

    Price

    $149.95
  2. Frequency Codes

    Frequency Codes

    Item

    FC-F12

    Price

    $149.95
 
 

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