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["附件7-6"]
[]
["______省(区、市）跨省异地就医应收医疗费用清算表"]
[]
["制表单位：（部级经办机构签章）"]
["清算所属月份：XX年XX月",null,null,"单位：元（保留两位小数）"]
["地  区","合计","职工医保","居民医保","新农合"]
["北  京"]
["天  津"]
["河  北"]
["山  西"]
["内蒙古"]
["辽  宁"]
["吉  林"]
["黑龙江"]
["上  海"]
["……"]
["合  计"]
[]
["单位负责人：                审核人：                制表人：               制表日期：      "]

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