Payer Specification Sheet
455-EM PRESCRIPTION/SERVICE REFERENCE NUMBER QUALIFIER 1-Rx Billing M 4Ø2-D2 PRESCRIPTION/SERVICE REFERENCE NUMBER M 436-E1 PRODUCT/SERVICE ID QUALIFIER Ø3-National Drug Code (NDC) M If billing for a Multi-Ingredient Compound, value is “ØØ”-Not Specified 407-D7 PRODUCT/SERVICE ID M NDC Number If billing for a
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Payer Specification Sheet
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