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| Roster Reference | [Value] | Roster Submission Date | [Date] |
|---|---|---|---|
| Roster Line Item Reference | [Value] | Case Reference | [field-value] |
| Service Authorization Reference | [field-value] | Service | [field-value] |
| Client Name | [A. Name] | Client Reference | [field-value] |
| Service Date From | [Date] | Service Date To | [Date] |
| Provider Group Reference | [field-value] | Provider Group Name | [field-value] |
| Amount | [Amount] |