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TOPS®: Insurance/UB04 Hospital Claim, 8-1/2 x 11, 2500 Continuous Forms/Carton
	Quantity in Basket: None Code: TOP-59770R Price: $118.44
	Quantity:
TOPS® UB04 Hospital Insurance Claim Form UB04 hospital insurance claim form. Printed to Government Printing Office standards. OCR ink for scanning. American Medical Association (AMA) approved format. • Weight = 28 lbs/CT • Mfgr Code: 59770R • Mfgr Name: TOPS BUSINESS FORMS • PRICED PER CT List Price = $146.19 Our Price = $118.44 Your Savings = $27.75 If your SHIP TO address is in California, you will receive a second invoice showing the California SALES TAX that you paid for this item