Name of Provider if not listed: 

                          Complete codes and fees.

Unit Supported: Location:

Specific Date(s):   Enter Number of Procedures Performed:

D0120  D0140  D0150  D0460  D0220  D0230             

D0272  D0330  D1320  D1330  D9310  D9973               

Additional procedures not listed: 

           

Comments: 

If additional dates or units supported by this provider, complete section below.  Otherwise proceed to "Submit" button.                             

Unit Supported: Location:

Specific Date(s):   Enter Number of Procedures Performed:

D0120  D0140  D0150  D0460  D0220  D0230  

D0272  D0330  D1320  D1330  D9310  D9973               

Additional procedures not listed: 

 

Comments: 

If you are satisfied with your entries, press "Submit." If not, change them now or press "Reset" to clear form.

You may download a blank 4th Den Co DIRS form here, open it in Excel, fill it out, and forward it via e-mail.


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