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Ultrasound Per Diem Fee Form
Ultrasound Per Diem Fee Form
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Contractor Name
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Email
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Date Performed
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Scan Performed
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Fee ($)
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Fee (%)
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Client Name
*
First
Last
Patient Name
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Date Performed
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Patient Name
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Add additional procedure?
*
Yes
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Date Performed
*
Scan Performed
*
Fee ($)
*
Fee (%)
*
Client Name
*
First
Last
Patient Name
*
Add additional procedure?
*
Yes
No
Date Performed
*
Scan Performed
*
Fee ($)
*
Fee (%)
*
Client Name
*
First
Last
Patient Name
*
Add additional procedure?
*
Yes
No
Date Performed
*
Scan Performed
*
Fee ($)
*
Fee (%)
*
Client Name
*
First
Last
Patient Name
*
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