| Company Information |
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Required
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Required
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Optional
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Required
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Optional
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Optional
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| A. AVAILABLE PREMIUM CREDITS |
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Optional
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| B. PROFESSIONAL LIABILITY COVERAGE |
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Required
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Required
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Optional
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| Please provide the percentages (based on number of procedures) of your practice which fall into the following CDT codes (must total 100%) |
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Optional
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Optional
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Optional
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Optional
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Optional
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Optional
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Optional
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Optional
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Optional
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Optional
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Optional
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Required
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| If "yes," please estimate the percentage each surgical procedure bears to your total practice (based on numbers of procedures) on an annual basis. |
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Optional
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Optional
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Optional
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Optional
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Required
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Required
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Optional
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Required
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Optional
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Submission Validation Required |
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