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["附件5"]
["市（州）新增医疗机构制剂信息申报汇总表"]
["填报单位（盖章）：",{"$nulls":9},"联系人：",{"$nulls":4},"联系电话："]
["序号","市州名称","使用单位名称","制剂类别","制剂名称","国家制剂代码","剂型","规格","包装","原辅料","适应症或功能主治","单个疗程费用","主要临床科室","批准/备案文号","批准/备案有效期至","是否委托配置","医疗机构联系人","联系电话","核算成本价格","申报的医保支付标准","初审建议的医保支付标准","初审建议的自付比例"]