[{"HCPCS_CD":"27036","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"518.45","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"37243","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"524.16","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"12051","HCPCS_INITIAL_MODIFIER_CD":"SG","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"81.95","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"87206","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"56","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"7.19","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"28825","HCPCS_INITIAL_MODIFIER_CD":"T2","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"AQ","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"861.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"27506","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"996.73","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"81001","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"1575","SUBMITTED_CHARGE_AMT":"33746.73","ALLOWED_CHARGE_AMT":"6583.68","DENIED_SERVICES_CNT":"51","DENIED_CHARGE_AMT":"1041.34","ASSIGNED_SERVICES_CNT":"1575","NCH_PAYMENT_AMT":"6411.14","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1C"},{"HCPCS_CD":"44640","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"171.06","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"92950","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"10102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"141.35","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"93010","HCPCS_INITIAL_MODIFIER_CD":"GZ","PROVIDER_SPEC_CD":"46","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2A"},{"HCPCS_CD":"84466","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"34.14","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"31579","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"45","SUBMITTED_CHARGE_AMT":"32706.4","ALLOWED_CHARGE_AMT":"9913.02","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"45","NCH_PAYMENT_AMT":"7738.04","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8H"},{"HCPCS_CD":"82565","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"27.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"22585","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2253.76","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"3110F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"L1906","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"99","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"14","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"489.32","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"74480","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"45","SUBMITTED_CHARGE_AMT":"3061","ALLOWED_CHARGE_AMT":"1207.87","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"45","NCH_PAYMENT_AMT":"946.86","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"L3030","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"23","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"1680","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"12","DENIED_CHARGE_AMT":"1680","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"J3420","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"12","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"L2340","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"55","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"383.12","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"57","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"220.05","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"25600","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"110.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"57530","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"97112","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"5717","SUBMITTED_CHARGE_AMT":"326635.46","ALLOWED_CHARGE_AMT":"175714.71","DENIED_SERVICES_CNT":"213","DENIED_CHARGE_AMT":"11583.33","ASSIGNED_SERVICES_CNT":"5717","NCH_PAYMENT_AMT":"137327.81","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"88304","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"J4","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"78","SUBMITTED_CHARGE_AMT":"7222.65","ALLOWED_CHARGE_AMT":"871.64","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"78","NCH_PAYMENT_AMT":"672.61","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"G0431","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"1040","SUBMITTED_CHARGE_AMT":"207715","ALLOWED_CHARGE_AMT":"90569.6","DENIED_SERVICES_CNT":"127","DENIED_CHARGE_AMT":"24895","ASSIGNED_SERVICES_CNT":"1040","NCH_PAYMENT_AMT":"87341.07","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"L3760","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"33","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"7806.88","ALLOWED_CHARGE_AMT":"5791.8","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"4540.8","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"27524","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"568.73","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"10060","HCPCS_INITIAL_MODIFIER_CD":"52","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"84.3","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"3072F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"71","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"29","SUBMITTED_CHARGE_AMT":"0","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"29","DENIED_CHARGE_AMT":"0","ASSIGNED_SERVICES_CNT":"29","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"70250","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"17.36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"32405","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"25","SUBMITTED_CHARGE_AMT":"7983","ALLOWED_CHARGE_AMT":"2451.23","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"25","NCH_PAYMENT_AMT":"1921.78","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"L2810","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"215.98","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"22325","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"781.12","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"A4206","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"19","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"991","SUBMITTED_CHARGE_AMT":"403","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"991","DENIED_CHARGE_AMT":"403","ASSIGNED_SERVICES_CNT":"991","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1A"},{"HCPCS_CD":"11042","HCPCS_INITIAL_MODIFIER_CD":"77","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"58","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"48.56","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"99233","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"81","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"468.76","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"29280","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"23.91","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"45171","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2940.18","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"43246","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"170.13","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"1613","SUBMITTED_CHARGE_AMT":"193278.31","ALLOWED_CHARGE_AMT":"113365.89","DENIED_SERVICES_CNT":"42","DENIED_CHARGE_AMT":"5235.69","ASSIGNED_SERVICES_CNT":"1613","NCH_PAYMENT_AMT":"87004.91","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"83735","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"G8419","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"140","SUBMITTED_CHARGE_AMT":"0","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"140","DENIED_CHARGE_AMT":"0","ASSIGNED_SERVICES_CNT":"140","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"69210","HCPCS_INITIAL_MODIFIER_CD":"52","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"73.98","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"24545","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"822.1","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"25101","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"174.21","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"25607","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"89.2","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"00910","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"P1","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"103.39","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"49000","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"555.7","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"93018","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"182","SUBMITTED_CHARGE_AMT":"14196","ALLOWED_CHARGE_AMT":"2536.56","DENIED_SERVICES_CNT":"26","DENIED_CHARGE_AMT":"2028","ASSIGNED_SERVICES_CNT":"182","NCH_PAYMENT_AMT":"1797.03","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2B"},{"HCPCS_CD":"L3807","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"CG","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"313.6","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"20600","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"65.76","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"20650","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"144.42","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"71270","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"196.18","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"37238","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"5836.58","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"32551","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"145.06","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"J9217","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15160","SUBMITTED_CHARGE_AMT":"11607237.21","ALLOWED_CHARGE_AMT":"3198238.75","DENIED_SERVICES_CNT":"596","DENIED_CHARGE_AMT":"436141.2","ASSIGNED_SERVICES_CNT":"15160","NCH_PAYMENT_AMT":"2483171.28","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"O1D"},{"HCPCS_CD":"11311","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"80.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"G8979","HCPCS_INITIAL_MODIFIER_CD":"CI","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GP","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"72192","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"180.75","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"440.1","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"40808","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"19","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"14","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"103.7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"23412","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"63","SUBMITTED_CHARGE_AMT":"151826.63","ALLOWED_CHARGE_AMT":"51738.32","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"63","NCH_PAYMENT_AMT":"39954.08","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"E2213","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"22","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"00410","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"53","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"80.41","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"J9181","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"7670","SUBMITTED_CHARGE_AMT":"63632.79","ALLOWED_CHARGE_AMT":"5175.91","DENIED_SERVICES_CNT":"166","DENIED_CHARGE_AMT":"592","ASSIGNED_SERVICES_CNT":"7670","NCH_PAYMENT_AMT":"4053.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1D"},{"HCPCS_CD":"76942","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"416.29","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3F"},{"HCPCS_CD":"E0629","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"41","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"567.06","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"A0425","HCPCS_INITIAL_MODIFIER_CD":"PH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1A"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"66.74","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"99283","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"56","SUBMITTED_CHARGE_AMT":"20698","ALLOWED_CHARGE_AMT":"3287.9","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"56","NCH_PAYMENT_AMT":"2483.58","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M3"},{"HCPCS_CD":"83518","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"450","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"18","DENIED_CHARGE_AMT":"450","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"64405","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"27602","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"183.69","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"13121","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"451.67","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"G0453","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"23","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"138","SUBMITTED_CHARGE_AMT":"20700","ALLOWED_CHARGE_AMT":"1020.48","DENIED_SERVICES_CNT":"106","DENIED_CHARGE_AMT":"15900","ASSIGNED_SERVICES_CNT":"138","NCH_PAYMENT_AMT":"800.07","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"26951","HCPCS_INITIAL_MODIFIER_CD":"F2","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"578.22","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"V2745","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"G8982","HCPCS_INITIAL_MODIFIER_CD":"CI","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"12","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GP","SUBMITTED_SERVICE_CNT":"230","SUBMITTED_CHARGE_AMT":"0.68","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"230","DENIED_CHARGE_AMT":"0.68","ASSIGNED_SERVICES_CNT":"230","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"32668","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"122.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"29515","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"21.64","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"01630","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"93.54","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"17003","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"403","SUBMITTED_CHARGE_AMT":"7509.83","ALLOWED_CHARGE_AMT":"3436.88","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"403","NCH_PAYMENT_AMT":"2504.27","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"01820","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"37","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"180.71","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"11055","HCPCS_INITIAL_MODIFIER_CD":"TA","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.78","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"65855","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"60","SUBMITTED_CHARGE_AMT":"70701.4","ALLOWED_CHARGE_AMT":"21305.16","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"60","NCH_PAYMENT_AMT":"16429.93","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"1124F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"0.11","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"0.11","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"3084.72","ALLOWED_CHARGE_AMT":"815.4","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"607.44","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"J0670","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1.98","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"73218","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"267.56","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2D"},{"HCPCS_CD":"01474","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1171.76","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"96413","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11614","SUBMITTED_CHARGE_AMT":"5486593.2","ALLOWED_CHARGE_AMT":"1673827.54","DENIED_SERVICES_CNT":"278","DENIED_CHARGE_AMT":"132275.44","ASSIGNED_SERVICES_CNT":"11614","NCH_PAYMENT_AMT":"1292880.89","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P7B"},{"HCPCS_CD":"11045","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"133","SUBMITTED_CHARGE_AMT":"12454","ALLOWED_CHARGE_AMT":"286","DENIED_SERVICES_CNT":"122","DENIED_CHARGE_AMT":"11440","ASSIGNED_SERVICES_CNT":"133","NCH_PAYMENT_AMT":"224.18","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"73140","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"49","HCPCS_SECOND_MODIFIER_CD":"F7","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"19.34","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"76857","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"29.88","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I3B"},{"HCPCS_CD":"A0427","HCPCS_INITIAL_MODIFIER_CD":"RH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"150","SUBMITTED_CHARGE_AMT":"117400.22","ALLOWED_CHARGE_AMT":"57207.91","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"150","NCH_PAYMENT_AMT":"44587.81","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1A"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"93.61","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"28285","HCPCS_INITIAL_MODIFIER_CD":"T2","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"362.74","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"99496","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"AO","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"180.76","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"84153","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"7273","SUBMITTED_CHARGE_AMT":"500575.18","ALLOWED_CHARGE_AMT":"176081.62","DENIED_SERVICES_CNT":"255","DENIED_CHARGE_AMT":"17265.09","ASSIGNED_SERVICES_CNT":"7273","NCH_PAYMENT_AMT":"169275.94","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"38746","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"165.59","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"74170","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"114.44","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"A4425","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"80","SUBMITTED_CHARGE_AMT":"472","ALLOWED_CHARGE_AMT":"313.6","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"80","NCH_PAYMENT_AMT":"245.88","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"62311","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"25","SUBMITTED_CHARGE_AMT":"22388","ALLOWED_CHARGE_AMT":"1134.56","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"25","NCH_PAYMENT_AMT":"889.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"99233","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"83.09","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"28210","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"28.54","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"93010","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"32.97","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2A"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"150","SUBMITTED_CHARGE_AMT":"24755","ALLOWED_CHARGE_AMT":"6574.9","DENIED_SERVICES_CNT":"18","DENIED_CHARGE_AMT":"2897","ASSIGNED_SERVICES_CNT":"150","NCH_PAYMENT_AMT":"5116.93","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"27598","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"557.95","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"45385","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"172","SUBMITTED_CHARGE_AMT":"429350","ALLOWED_CHARGE_AMT":"48015.03","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"24271","ASSIGNED_SERVICES_CNT":"172","NCH_PAYMENT_AMT":"36513.71","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8D"},{"HCPCS_CD":"99342","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"2167.92","ALLOWED_CHARGE_AMT":"1007.77","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"790.09","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4A"},{"HCPCS_CD":"13102","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"A4930","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"L","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P9B"},{"HCPCS_CD":"73560","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"02102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"35","SUBMITTED_CHARGE_AMT":"1895","ALLOWED_CHARGE_AMT":"428.4","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"35","NCH_PAYMENT_AMT":"316.16","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"13122","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"120.8","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"31502","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"27.97","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"11420","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"48","SUBMITTED_CHARGE_AMT":"10746.21","ALLOWED_CHARGE_AMT":"5071.88","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"48","NCH_PAYMENT_AMT":"3454.36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"73030","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"D2","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"21","SUBMITTED_CHARGE_AMT":"658","ALLOWED_CHARGE_AMT":"218.19","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"21","NCH_PAYMENT_AMT":"170.94","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"50542","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"430.08","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P8I"},{"HCPCS_CD":"15740","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1956.7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"25607","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"19916.88","ALLOWED_CHARGE_AMT":"6484.71","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"4605.59","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"28299","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"10102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2527.5","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"G8754","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"298","SUBMITTED_CHARGE_AMT":"1.02","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"298","DENIED_CHARGE_AMT":"1.02","ASSIGNED_SERVICES_CNT":"298","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5B"},{"HCPCS_CD":"64635","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"284.42","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"L5651","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"52","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"K2","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1768.92","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"11302","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"125.82","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"22902","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"138.59","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"G8987","HCPCS_INITIAL_MODIFIER_CD":"GO","PROVIDER_SPEC_CD":"67","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CJ","SUBMITTED_SERVICE_CNT":"64","SUBMITTED_CHARGE_AMT":"0.41","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"64","DENIED_CHARGE_AMT":"0.41","ASSIGNED_SERVICES_CNT":"64","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"E2313","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"22","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KH","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"274.71","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"70551","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"Q6","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"272.13","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2C"},{"HCPCS_CD":"92929","HCPCS_INITIAL_MODIFIER_CD":"RC","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"76","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2D"},{"HCPCS_CD":"27047","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"08","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1342.88","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"99350","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"25","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.64","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4A"},{"HCPCS_CD":"33216","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"256.39","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2E"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"78.11","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"73090","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"22.3","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"29125","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"4522","ALLOWED_CHARGE_AMT":"633.2","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"464.76","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"73565","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"31.07","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"21210","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"19","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"83036","HCPCS_INITIAL_MODIFIER_CD":"GZ","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"20551","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"336.84","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"01380","HCPCS_INITIAL_MODIFIER_CD":"QY","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"16","SUBMITTED_CHARGE_AMT":"13416.5","ALLOWED_CHARGE_AMT":"733.6","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"16","NCH_PAYMENT_AMT":"575.14","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"97602","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"185","SUBMITTED_CHARGE_AMT":"16085.9","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"185","DENIED_CHARGE_AMT":"16085.9","ASSIGNED_SERVICES_CNT":"185","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"58300","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"2736","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"12","DENIED_CHARGE_AMT":"2736","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"12051","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"187.76","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"E0971","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"A6","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"28230","HCPCS_INITIAL_MODIFIER_CD":"T2","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"50398","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GV","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"86.78","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"29240","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"1262","ALLOWED_CHARGE_AMT":"534.96","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"419.4","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"L5647","HCPCS_INITIAL_MODIFIER_CD":"K3","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"10","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"585.84","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"11721","HCPCS_INITIAL_MODIFIER_CD":"Q8","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"33","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"567","SUBMITTED_CHARGE_AMT":"35216.64","ALLOWED_CHARGE_AMT":"24950.9","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"567","NCH_PAYMENT_AMT":"16299.55","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"62267","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"125.19","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"52352","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"76","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8E"},{"HCPCS_CD":"31615","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"111.16","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8F"},{"HCPCS_CD":"98943","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GX","SUBMITTED_SERVICE_CNT":"102","SUBMITTED_CHARGE_AMT":"4530","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"102","DENIED_CHARGE_AMT":"4530","ASSIGNED_SERVICES_CNT":"102","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1B"},{"HCPCS_CD":"42420","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"923.64","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"57282","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"225.98","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"73610","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"375","SUBMITTED_CHARGE_AMT":"31579.82","ALLOWED_CHARGE_AMT":"8759.75","DENIED_SERVICES_CNT":"36","DENIED_CHARGE_AMT":"3259.1","ASSIGNED_SERVICES_CNT":"375","NCH_PAYMENT_AMT":"6032.24","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"11043","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"24575","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"316.95","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"30901","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"68.35","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"35631","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2864.9","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"G0919","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"03","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"86","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"22","SUBMITTED_CHARGE_AMT":"616","ALLOWED_CHARGE_AMT":"540.1","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"22","NCH_PAYMENT_AMT":"404.25","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"23195","HCPCS_INITIAL_MODIFIER_CD":"82","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"AS","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"131.88","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"96374","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"13292","PRICING_LOCALITY_CD":"C5","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"159.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GY","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"72010","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"76.43","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"44120","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"81","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"52","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1200.38","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"G0442","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Y1"},{"HCPCS_CD":"E0470","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"A6","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KJ","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.79","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"E0470","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KJ","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"93288","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"A4233","HCPCS_INITIAL_MODIFIER_CD":"KL","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"~","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"NU","SUBMITTED_SERVICE_CNT":"16","SUBMITTED_CHARGE_AMT":"17.96","ALLOWED_CHARGE_AMT":"5.8","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"16","NCH_PAYMENT_AMT":"3.64","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"92612","HCPCS_INITIAL_MODIFIER_CD":"GN","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"13","SUBMITTED_CHARGE_AMT":"3146","ALLOWED_CHARGE_AMT":"946.79","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"13","NCH_PAYMENT_AMT":"742.17","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P8I"},{"HCPCS_CD":"33999","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"93784","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"132.12","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"99204","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"357.96","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"G8985","HCPCS_INITIAL_MODIFIER_CD":"CL","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GP","SUBMITTED_SERVICE_CNT":"159","SUBMITTED_CHARGE_AMT":"0.24","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"159","DENIED_CHARGE_AMT":"0.24","ASSIGNED_SERVICES_CNT":"159","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"47525","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"18782","ALLOWED_CHARGE_AMT":"672.32","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"527.12","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"G8984","HCPCS_INITIAL_MODIFIER_CD":"CK","PROVIDER_SPEC_CD":"67","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GO","SUBMITTED_SERVICE_CNT":"399","SUBMITTED_CHARGE_AMT":"0.23","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"399","DENIED_CHARGE_AMT":"0.23","ASSIGNED_SERVICES_CNT":"399","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"80053","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1B"},{"HCPCS_CD":"J9201","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"165","ALLOWED_CHARGE_AMT":"73.21","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"57.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1D"},{"HCPCS_CD":"99234","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"604.1","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"70460","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"306.46","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2A"},{"HCPCS_CD":"11750","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"227.88","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"49424","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"30.26","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"28285","HCPCS_INITIAL_MODIFIER_CD":"T4","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"14755","ALLOWED_CHARGE_AMT":"6399.67","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"4902","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"28230","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"124.9","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"44005","HCPCS_INITIAL_MODIFIER_CD":"82","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"130.11","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"82977","HCPCS_INITIAL_MODIFIER_CD":"91","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"9.62","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"71020","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"8.31","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1A"},{"HCPCS_CD":"20600","HCPCS_INITIAL_MODIFIER_CD":"TA","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3.07","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"76519","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"H8","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"675","ALLOWED_CHARGE_AMT":"462.6","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"314.34","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I3A"},{"HCPCS_CD":"G8597","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"43","SUBMITTED_CHARGE_AMT":"0.39","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"43","DENIED_CHARGE_AMT":"0.39","ASSIGNED_SERVICES_CNT":"43","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"77001","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"AQ","SUBMITTED_SERVICE_CNT":"13","SUBMITTED_CHARGE_AMT":"2951","ALLOWED_CHARGE_AMT":"243.49","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"13","NCH_PAYMENT_AMT":"190.84","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"84154","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"335","SUBMITTED_CHARGE_AMT":"17219","ALLOWED_CHARGE_AMT":"7903.35","DENIED_SERVICES_CNT":"20","DENIED_CHARGE_AMT":"1028","ASSIGNED_SERVICES_CNT":"335","NCH_PAYMENT_AMT":"7745.85","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"70498","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"B8","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"216.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2A"},{"HCPCS_CD":"A0425","HCPCS_INITIAL_MODIFIER_CD":"HH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"290.1","SUBMITTED_CHARGE_AMT":"8899.11","ALLOWED_CHARGE_AMT":"2077.12","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"290.1","NCH_PAYMENT_AMT":"1628.47","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1A"},{"HCPCS_CD":"74177","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"H9","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"77","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"211.98","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"73630","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"1147.6","ALLOWED_CHARGE_AMT":"288.61","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"226.28","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"45340","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"98.7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8I"},{"HCPCS_CD":"68760","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"99.9","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"52285","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"447.42","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8E"},{"HCPCS_CD":"82247","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"54","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"00920","HCPCS_INITIAL_MODIFIER_CD":"QY","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"122.37","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"64494","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"137.86","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"87449","HCPCS_INITIAL_MODIFIER_CD":"91","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"80.15","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"J0702","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"36","SUBMITTED_CHARGE_AMT":"360","ALLOWED_CHARGE_AMT":"159.98","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"36","NCH_PAYMENT_AMT":"125.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"93352","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"121.88","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3C"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"610","SUBMITTED_CHARGE_AMT":"49301","ALLOWED_CHARGE_AMT":"20957.36","DENIED_SERVICES_CNT":"85","DENIED_CHARGE_AMT":"5518","ASSIGNED_SERVICES_CNT":"610","NCH_PAYMENT_AMT":"15437.84","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"17271","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"61","SUBMITTED_CHARGE_AMT":"15167.25","ALLOWED_CHARGE_AMT":"5108.75","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"61","NCH_PAYMENT_AMT":"4005.26","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"49525","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3911.7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5C"},{"HCPCS_CD":"84460","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"94","SUBMITTED_CHARGE_AMT":"2425","ALLOWED_CHARGE_AMT":"433.3","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"94","NCH_PAYMENT_AMT":"424.49","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"A7004","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RB","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1.55","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"65800","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"21","SUBMITTED_CHARGE_AMT":"6036","ALLOWED_CHARGE_AMT":"2772.21","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"21","NCH_PAYMENT_AMT":"2133.11","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"32555","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"97.98","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"G0145","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"17","SUBMITTED_CHARGE_AMT":"1564","ALLOWED_CHARGE_AMT":"469.82","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"17","NCH_PAYMENT_AMT":"460.46","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"25295","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"61320","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"698.47","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"11600","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"28","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"47.05","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"37223","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1861.26","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"70553","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"56","SUBMITTED_CHARGE_AMT":"14336","ALLOWED_CHARGE_AMT":"122.78","DENIED_SERVICES_CNT":"55","DENIED_CHARGE_AMT":"14080","ASSIGNED_SERVICES_CNT":"56","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2C"},{"HCPCS_CD":"99001","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"9","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"23420","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"103.19","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"J1030","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"5.1","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"11046","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"58","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"43.99","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"00830","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"P4","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"109.11","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"17106","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"222.44","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"10140","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"161.22","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"43248","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"101.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8B"},{"HCPCS_CD":"01200","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"29","SUBMITTED_CHARGE_AMT":"29745.93","ALLOWED_CHARGE_AMT":"2016.54","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"29","NCH_PAYMENT_AMT":"1526.29","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"22848","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"345.6","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"147.1","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"51729","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"208.26","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"64450","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"J1940","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"27","SUBMITTED_CHARGE_AMT":"869.53","ALLOWED_CHARGE_AMT":"114.83","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"27","NCH_PAYMENT_AMT":"90.03","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"27130","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"172.08","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3B"},{"HCPCS_CD":"99307","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"231","SUBMITTED_CHARGE_AMT":"13795","ALLOWED_CHARGE_AMT":"10018.65","DENIED_SERVICES_CNT":"14","DENIED_CHARGE_AMT":"870","ASSIGNED_SERVICES_CNT":"230","NCH_PAYMENT_AMT":"7117.59","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"77262","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"837.08","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P7A"},{"HCPCS_CD":"0521F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"L3995","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"24","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1.96","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"28740","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"240.44","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"11042","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"95.18","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"73000","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.48","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"64831","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"F2","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"00914","HCPCS_INITIAL_MODIFIER_CD":"QY","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"58.22","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"76881","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"72.81","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I3F"},{"HCPCS_CD":"75625","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"320.11","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"99223","HCPCS_INITIAL_MODIFIER_CD":"AI","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"30","SUBMITTED_CHARGE_AMT":"13191","ALLOWED_CHARGE_AMT":"5874.24","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"30","NCH_PAYMENT_AMT":"4490.24","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"11004","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"432.47","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"4179F","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"27130","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1199.52","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3B"},{"HCPCS_CD":"20225","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"44.32","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"01520","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"32","CARRIER_NUM":"14512","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"102.53","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"90662","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"65.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1G"},{"HCPCS_CD":"99233","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"116","SUBMITTED_CHARGE_AMT":"27874.8","ALLOWED_CHARGE_AMT":"10890.6","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"2404.4","ASSIGNED_SERVICES_CNT":"116","NCH_PAYMENT_AMT":"8392.02","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"44960","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"97.89","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"85025","HCPCS_INITIAL_MODIFIER_CD":"Q5","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"41.6","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1D"},{"HCPCS_CD":"36580","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"95.38","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"28297","HCPCS_INITIAL_MODIFIER_CD":"SG","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1042.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"J0702","HCPCS_INITIAL_MODIFIER_CD":"FA","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"4.38","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"12001","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"1091F","HCPCS_INITIAL_MODIFIER_CD":"1P","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"0","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"0","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"85060","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"B5","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.23","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"29877","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"10","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2662.65","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8A"},{"HCPCS_CD":"70496","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"59","SUBMITTED_CHARGE_AMT":"77425.86","ALLOWED_CHARGE_AMT":"18239.26","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"59","NCH_PAYMENT_AMT":"13760.4","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2A"},{"HCPCS_CD":"00160","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"13292","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"22","SUBMITTED_CHARGE_AMT":"30531.27","ALLOWED_CHARGE_AMT":"3341.13","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"22","NCH_PAYMENT_AMT":"2619.44","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"E0971","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"23","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3.73","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"31625","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"199.14","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8F"},{"HCPCS_CD":"A4352","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"A6","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"24","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"111","SUBMITTED_CHARGE_AMT":"780.55","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"111","DENIED_CHARGE_AMT":"780.55","ASSIGNED_SERVICES_CNT":"111","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"A4362","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"121.62","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"41.63","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"62284","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"75.71","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"97530","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"20690","HCPCS_INITIAL_MODIFIER_CD":"T5","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"235.14","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"80174","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"46.02","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"20550","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"17.78","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"15850","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"99","SUBMITTED_CHARGE_AMT":"1690","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"99","DENIED_CHARGE_AMT":"1690","ASSIGNED_SERVICES_CNT":"99","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"E0190","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"9","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"3022F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"53.04","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"45384","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"223.54","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8D"},{"HCPCS_CD":"92226","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"280","SUBMITTED_CHARGE_AMT":"26560.92","ALLOWED_CHARGE_AMT":"7552.86","DENIED_SERVICES_CNT":"32","DENIED_CHARGE_AMT":"3200","ASSIGNED_SERVICES_CNT":"280","NCH_PAYMENT_AMT":"5758.71","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5C"},{"HCPCS_CD":"67210","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"387.04","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4D"},{"HCPCS_CD":"20600","HCPCS_INITIAL_MODIFIER_CD":"T4","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"1123F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"28298","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"25.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"44361","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"10102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"63.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8I"},{"HCPCS_CD":"L1906","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"33","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"335.82","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"73630","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"T4","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"90732","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"454","SUBMITTED_CHARGE_AMT":"35612.33","ALLOWED_CHARGE_AMT":"25537.5","DENIED_SERVICES_CNT":"84","DENIED_CHARGE_AMT":"6953","ASSIGNED_SERVICES_CNT":"454","NCH_PAYMENT_AMT":"24905.67","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1G"},{"HCPCS_CD":"75989","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"45.52","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"93306","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"81","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"127.46","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3C"},{"HCPCS_CD":"4045F","HCPCS_INITIAL_MODIFIER_CD":"8P","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"90970","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"65","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"3510","SUBMITTED_CHARGE_AMT":"85876","ALLOWED_CHARGE_AMT":"23029.14","DENIED_SERVICES_CNT":"593","DENIED_CHARGE_AMT":"14948","ASSIGNED_SERVICES_CNT":"3510","NCH_PAYMENT_AMT":"18051.06","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P9A"},{"HCPCS_CD":"36225","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"258.5","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"73562","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"H9","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"28.05","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"00540","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"P3","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"307.47","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"22845","HCPCS_INITIAL_MODIFIER_CD":"62","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"382.68","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"22614","HCPCS_INITIAL_MODIFIER_CD":"82","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"28","SUBMITTED_CHARGE_AMT":"15702.4","ALLOWED_CHARGE_AMT":"1834.04","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"28","NCH_PAYMENT_AMT":"1437.88","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"79.95","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"22532","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"80","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"199.89","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"64772","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"88187","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"99","SUBMITTED_CHARGE_AMT":"19101.18","ALLOWED_CHARGE_AMT":"6527.19","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"99","NCH_PAYMENT_AMT":"5061.76","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"36800","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"58.14","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"37221","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1693.04","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"71110","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"27","SUBMITTED_CHARGE_AMT":"8506.95","ALLOWED_CHARGE_AMT":"1006.75","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"27","NCH_PAYMENT_AMT":"735.49","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"37.29","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"78815","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"82","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"PS","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"4737.5","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2D"},{"HCPCS_CD":"J7030","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"19","SUBMITTED_CHARGE_AMT":"84.34","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"19","DENIED_CHARGE_AMT":"84.34","ASSIGNED_SERVICES_CNT":"19","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"A6220","HCPCS_INITIAL_MODIFIER_CD":"A1","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"1655","SUBMITTED_CHARGE_AMT":"5573.99","ALLOWED_CHARGE_AMT":"4420.85","DENIED_SERVICES_CNT":"90","DENIED_CHARGE_AMT":"277.76","ASSIGNED_SERVICES_CNT":"1655","NCH_PAYMENT_AMT":"3406.84","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1A"},{"HCPCS_CD":"45380","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"42","SUBMITTED_CHARGE_AMT":"46835.62","ALLOWED_CHARGE_AMT":"11684.34","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"42","NCH_PAYMENT_AMT":"8763.73","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8D"},{"HCPCS_CD":"G0206","HCPCS_INITIAL_MODIFIER_CD":"52","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"47.81","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1C"},{"HCPCS_CD":"70549","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"87","SUBMITTED_CHARGE_AMT":"50663.39","ALLOWED_CHARGE_AMT":"5593.1","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"87","NCH_PAYMENT_AMT":"4384.92","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2C"},{"HCPCS_CD":"28118","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"180.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"A7003","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"J9260","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1.66","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1D"},{"HCPCS_CD":"27758","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1394.2","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"4048F","HCPCS_INITIAL_MODIFIER_CD":"1P","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"108","SUBMITTED_CHARGE_AMT":"0","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"108","DENIED_CHARGE_AMT":"0","ASSIGNED_SERVICES_CNT":"108","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"28270","HCPCS_INITIAL_MODIFIER_CD":"T2","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"817.36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"28110","HCPCS_INITIAL_MODIFIER_CD":"T5","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"12","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"377.2","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"52332","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"62.94","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8E"},{"HCPCS_CD":"13121","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"780.5","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"73060","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"AQ","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"7.19","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"G8419","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"14563","SUBMITTED_CHARGE_AMT":"7.96","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"14563","DENIED_CHARGE_AMT":"7.96","ASSIGNED_SERVICES_CNT":"14562","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"27393","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"594.48","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"96372","HCPCS_INITIAL_MODIFIER_CD":"Q1","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.72","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"73560","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"8.06","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"10121","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"12","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"221.93","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"93922","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"63.59","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"L0486","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"53","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"33","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1399.02","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"56","SUBMITTED_CHARGE_AMT":"3151.01","ALLOWED_CHARGE_AMT":"1318.76","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"56","NCH_PAYMENT_AMT":"1014.52","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"72070","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"153","SUBMITTED_CHARGE_AMT":"17079.46","ALLOWED_CHARGE_AMT":"5138.1","DENIED_SERVICES_CNT":"13","DENIED_CHARGE_AMT":"1912.14","ASSIGNED_SERVICES_CNT":"153","NCH_PAYMENT_AMT":"4028.18","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"31625","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"32","SUBMITTED_CHARGE_AMT":"22618.06","ALLOWED_CHARGE_AMT":"776.13","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"32","NCH_PAYMENT_AMT":"608.46","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8F"},{"HCPCS_CD":"37607","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"22","SUBMITTED_CHARGE_AMT":"16074.76","ALLOWED_CHARGE_AMT":"5950.04","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"22","NCH_PAYMENT_AMT":"4664.89","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"85025","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"204278","SUBMITTED_CHARGE_AMT":"6174578.9","ALLOWED_CHARGE_AMT":"1984592.24","DENIED_SERVICES_CNT":"17226","DENIED_CHARGE_AMT":"698953.36","ASSIGNED_SERVICES_CNT":"204278","NCH_PAYMENT_AMT":"1939602.43","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1D"},{"HCPCS_CD":"K0739","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"9","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"22","SUBMITTED_CHARGE_AMT":"668.5","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"22","DENIED_CHARGE_AMT":"668.5","ASSIGNED_SERVICES_CNT":"22","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"99204","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"84","SUBMITTED_CHARGE_AMT":"33640","ALLOWED_CHARGE_AMT":"11476.35","DENIED_SERVICES_CNT":"17","DENIED_CHARGE_AMT":"7677","ASSIGNED_SERVICES_CNT":"84","NCH_PAYMENT_AMT":"8184.58","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"97597","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"82.88","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"26720","HCPCS_INITIAL_MODIFIER_CD":"F4","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"38.33","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"35476","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"26","SUBMITTED_CHARGE_AMT":"87256","ALLOWED_CHARGE_AMT":"27227.8","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"26","NCH_PAYMENT_AMT":"21346.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"11042","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"81","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"87.83","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"69200","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"7.87","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"65210","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"84.22","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"20612","HCPCS_INITIAL_MODIFIER_CD":"F8","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"143.37","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"29825","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8A"},{"HCPCS_CD":"54161","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"685.84","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"12032","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"437.18","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"11100","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"364.3","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"73080","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"28.21","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"J1080","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"46","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"258","SUBMITTED_CHARGE_AMT":"12651.95","ALLOWED_CHARGE_AMT":"760.73","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"258","NCH_PAYMENT_AMT":"568.62","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"29888","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3253.41","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8A"},{"HCPCS_CD":"36833","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1524.75","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"L3332","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"02102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"29824","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"645.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"209.62","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"11602","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"998.62","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"L3923","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"CG","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"301.87","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"22595","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"340.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"27816","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"203.02","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"G0182","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"81.95","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Y1"},{"HCPCS_CD":"64721","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"79","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"461.79","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"L3030","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"GY","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"32555","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"44.24","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"G8988","HCPCS_INITIAL_MODIFIER_CD":"CK","PROVIDER_SPEC_CD":"67","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GO","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"99288","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M3"},{"HCPCS_CD":"93979","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"214.11","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3F"},{"HCPCS_CD":"73020","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"6.11","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"G8797","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"64","SUBMITTED_CHARGE_AMT":"0.02","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"64","DENIED_CHARGE_AMT":"0.02","ASSIGNED_SERVICES_CNT":"64","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5B"},{"HCPCS_CD":"88304","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"5383","SUBMITTED_CHARGE_AMT":"267615.06","ALLOWED_CHARGE_AMT":"58063.26","DENIED_SERVICES_CNT":"279","DENIED_CHARGE_AMT":"16855.66","ASSIGNED_SERVICES_CNT":"5224","NCH_PAYMENT_AMT":"45007.66","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"01630","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"QS","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"15972","ALLOWED_CHARGE_AMT":"3553.87","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"2786.23","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"82145","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"997","SUBMITTED_CHARGE_AMT":"48874.4","ALLOWED_CHARGE_AMT":"12847.2","DENIED_SERVICES_CNT":"391","DENIED_CHARGE_AMT":"17219.2","ASSIGNED_SERVICES_CNT":"997","NCH_PAYMENT_AMT":"12540.36","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"50684","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"42","SUBMITTED_CHARGE_AMT":"133560","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"42","DENIED_CHARGE_AMT":"133560","ASSIGNED_SERVICES_CNT":"42","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"28313","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"78805","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"82.92","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1E"},{"HCPCS_CD":"L8480","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"57","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"44","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"K1","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"43235","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"42","SUBMITTED_CHARGE_AMT":"32374","ALLOWED_CHARGE_AMT":"3034.16","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"42","NCH_PAYMENT_AMT":"2378.89","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8B"},{"HCPCS_CD":"81003","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"PD","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1C"},{"HCPCS_CD":"27676","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"464.93","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"64450","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"55.54","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"V2203","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"49","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"EY","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"80202","HCPCS_INITIAL_MODIFIER_CD":"91","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"90","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.12","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"92285","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"1782.28","ALLOWED_CHARGE_AMT":"55.26","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"40.97","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5C"},{"HCPCS_CD":"73590","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"6.8","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"39400","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"397.25","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P8I"},{"HCPCS_CD":"92012","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"40.87","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5C"},{"HCPCS_CD":"L3807","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"B1","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"23","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"336.48","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"79","SUBMITTED_CHARGE_AMT":"125194","ALLOWED_CHARGE_AMT":"14189.94","DENIED_SERVICES_CNT":"17","DENIED_CHARGE_AMT":"27087","ASSIGNED_SERVICES_CNT":"79","NCH_PAYMENT_AMT":"11010.03","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"64635","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"400.62","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"83925","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"208.08","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"G8484","HCPCS_INITIAL_MODIFIER_CD":"2P","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"24075","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"498.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"11056","HCPCS_INITIAL_MODIFIER_CD":"Q7","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"35.7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"35875","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"28810","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"TA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"172.36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"46050","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"99326","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"14","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"333.29","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"74175","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03602","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1221.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"29848","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1322.64","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8A"},{"HCPCS_CD":"42953","HCPCS_INITIAL_MODIFIER_CD":"82","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"AS","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"47.51","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"99318","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"Q5","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"239.88","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"28272","HCPCS_INITIAL_MODIFIER_CD":"T8","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"159.22","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"64450","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"80182","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"47","SUBMITTED_CHARGE_AMT":"869.03","ALLOWED_CHARGE_AMT":"240.12","DENIED_SERVICES_CNT":"29","DENIED_CHARGE_AMT":"536.21","ASSIGNED_SERVICES_CNT":"47","NCH_PAYMENT_AMT":"235.26","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"27187","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"811.39","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"27603","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"293.62","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"29877","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"80","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"6160","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"6160","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8A"},{"HCPCS_CD":"A4248","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"L","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"119","SUBMITTED_CHARGE_AMT":"703","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"119","DENIED_CHARGE_AMT":"703","ASSIGNED_SERVICES_CNT":"119","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P9B"},{"HCPCS_CD":"11623","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"160.9","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"73510","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"92","SUBMITTED_CHARGE_AMT":"9977.5","ALLOWED_CHARGE_AMT":"3297.36","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"92","NCH_PAYMENT_AMT":"2441.88","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"135.68","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"J7799","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"839.66","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1G"},{"HCPCS_CD":"J1040","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"77057","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"74.68","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1A"},{"HCPCS_CD":"1126F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"11730","HCPCS_INITIAL_MODIFIER_CD":"T5","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"46.28","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"80061","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"53.16","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"L3807","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"41","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"2200","ALLOWED_CHARGE_AMT":"2200","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"1650.99","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"E0601","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"51","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KH","SUBMITTED_SERVICE_CNT":"1148","SUBMITTED_CHARGE_AMT":"241103.77","ALLOWED_CHARGE_AMT":"74523.97","DENIED_SERVICES_CNT":"357","DENIED_CHARGE_AMT":"73682.7","ASSIGNED_SERVICES_CNT":"1148","NCH_PAYMENT_AMT":"57393.18","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"73520","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"21.28","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"67917","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1615.74","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"95923","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"115.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"34812","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"149.34","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"19380","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"916.05","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1A"},{"HCPCS_CD":"28011","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"T4","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"120.81","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"64415","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"489.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"77080","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"2705","SUBMITTED_CHARGE_AMT":"776511.53","ALLOWED_CHARGE_AMT":"102875.98","DENIED_SERVICES_CNT":"442","DENIED_CHARGE_AMT":"122630.14","ASSIGNED_SERVICES_CNT":"2705","NCH_PAYMENT_AMT":"100444.3","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"73510","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"G0439","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"14678","SUBMITTED_CHARGE_AMT":"2682189.42","ALLOWED_CHARGE_AMT":"1574746.4","DENIED_SERVICES_CNT":"1443","DENIED_CHARGE_AMT":"269330.4","ASSIGNED_SERVICES_CNT":"14678","NCH_PAYMENT_AMT":"1542973.43","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"A7046","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"A6","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"29914","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1608.36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8A"},{"HCPCS_CD":"49507","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1121.12","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"93227","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"02102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"24.49","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2C"},{"HCPCS_CD":"17271","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"752.78","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"43832","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"6638","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"88313","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"30.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"73080","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"314","ALLOWED_CHARGE_AMT":"105.6","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"75.9","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"36415","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2.94","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1A"},{"HCPCS_CD":"99336","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"27","SUBMITTED_CHARGE_AMT":"6932","ALLOWED_CHARGE_AMT":"3555.36","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"27","NCH_PAYMENT_AMT":"2160.14","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"15271","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"45","SUBMITTED_CHARGE_AMT":"13903.91","ALLOWED_CHARGE_AMT":"3840.14","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"45","NCH_PAYMENT_AMT":"3010.57","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"37225","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"301.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"E0971","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"RB","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"L4386","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"CC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"99307","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"15120","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1591.26","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"52000","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"248","SUBMITTED_CHARGE_AMT":"123219.14","ALLOWED_CHARGE_AMT":"28786.59","DENIED_SERVICES_CNT":"15","DENIED_CHARGE_AMT":"8607","ASSIGNED_SERVICES_CNT":"248","NCH_PAYMENT_AMT":"22348.07","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8E"},{"HCPCS_CD":"47780","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"91","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1807.28","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"G0439","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"188","SUBMITTED_CHARGE_AMT":"23862","ALLOWED_CHARGE_AMT":"17493.85","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"188","NCH_PAYMENT_AMT":"17143.45","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"17262","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"79","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"211.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"74000","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"E7","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"21.06","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"1090F","HCPCS_INITIAL_MODIFIER_CD":"1P","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"19","SUBMITTED_CHARGE_AMT":"0","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"19","DENIED_CHARGE_AMT":"0","ASSIGNED_SERVICES_CNT":"19","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"10140","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"AS","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"90838","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"26","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"346.08","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5B"},{"HCPCS_CD":"64483","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"238","SUBMITTED_CHARGE_AMT":"130870","ALLOWED_CHARGE_AMT":"55684.64","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"238","NCH_PAYMENT_AMT":"42302.33","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"6010F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"84100","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"137","SUBMITTED_CHARGE_AMT":"2630.68","ALLOWED_CHARGE_AMT":"491.3","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"137","NCH_PAYMENT_AMT":"470.43","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"99202","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"164.91","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"76700","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"103.07","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I3B"},{"HCPCS_CD":"99145","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"66","SUBMITTED_CHARGE_AMT":"6600","ALLOWED_CHARGE_AMT":"554.58","DENIED_SERVICES_CNT":"27","DENIED_CHARGE_AMT":"2700","ASSIGNED_SERVICES_CNT":"66","NCH_PAYMENT_AMT":"434.79","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"64632","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"23","SUBMITTED_CHARGE_AMT":"6823.6","ALLOWED_CHARGE_AMT":"1474.44","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"3313.4","ASSIGNED_SERVICES_CNT":"23","NCH_PAYMENT_AMT":"1155.99","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"G0436","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"86580","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"7.65","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"82565","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"157","SUBMITTED_CHARGE_AMT":"5322","ALLOWED_CHARGE_AMT":"230.56","DENIED_SERVICES_CNT":"108","DENIED_CHARGE_AMT":"3812","ASSIGNED_SERVICES_CNT":"157","NCH_PAYMENT_AMT":"225.93","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"27557","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"410.64","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"70540","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"136.01","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2C"},{"HCPCS_CD":"A0428","HCPCS_INITIAL_MODIFIER_CD":"NH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"319.32","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1A"},{"HCPCS_CD":"00400","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"108.35","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"33210","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2E"},{"HCPCS_CD":"21310","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"49.08","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"38900","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"101.18","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"38792","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"68.28","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"95926","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"715.68","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"87804","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"91.86","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"74230","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"Q6","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"150.85","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1D"},{"HCPCS_CD":"31611","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"989.1","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"10140","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"137.26","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"87205","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"1436","SUBMITTED_CHARGE_AMT":"28166.14","ALLOWED_CHARGE_AMT":"7472.88","DENIED_SERVICES_CNT":"152","DENIED_CHARGE_AMT":"2486.14","ASSIGNED_SERVICES_CNT":"1436","NCH_PAYMENT_AMT":"7318.8","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"70549","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"96","SUBMITTED_CHARGE_AMT":"32442.12","ALLOWED_CHARGE_AMT":"5960.08","DENIED_SERVICES_CNT":"38","DENIED_CHARGE_AMT":"13389.42","ASSIGNED_SERVICES_CNT":"96","NCH_PAYMENT_AMT":"4607.34","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2C"},{"HCPCS_CD":"74177","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"240.63","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"4047F","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"03","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"88.08","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"21390","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"634.86","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"28080","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"585.92","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"43262","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"38","SUBMITTED_CHARGE_AMT":"57388.09","ALLOWED_CHARGE_AMT":"1389.66","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"38","NCH_PAYMENT_AMT":"1089.46","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8B"},{"HCPCS_CD":"84153","HCPCS_INITIAL_MODIFIER_CD":"91","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"24.59","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"11442","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"316.01","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"37222","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"860.81","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"272.65","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"99211","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"41.25","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"G0009","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"25.34","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1G"},{"HCPCS_CD":"96375","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"16.16","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"83525","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"13292","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"144","SUBMITTED_CHARGE_AMT":"2284.95","ALLOWED_CHARGE_AMT":"2073.47","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"175.31","ASSIGNED_SERVICES_CNT":"144","NCH_PAYMENT_AMT":"2032.24","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"67924","HCPCS_INITIAL_MODIFIER_CD":"E4","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"79","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"205.85","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"42","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"28","SUBMITTED_CHARGE_AMT":"3409","ALLOWED_CHARGE_AMT":"2041.2","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"28","NCH_PAYMENT_AMT":"1541.02","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"371.24","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"61601","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"936.51","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"99231","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"22","SUBMITTED_CHARGE_AMT":"5275","ALLOWED_CHARGE_AMT":"915.6","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"22","NCH_PAYMENT_AMT":"688.02","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"11401","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"33975","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"70470","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"G5","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"107.36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2A"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"09302","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"17","SUBMITTED_CHARGE_AMT":"747.32","ALLOWED_CHARGE_AMT":"394.29","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"17","NCH_PAYMENT_AMT":"309.15","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"J0834","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"249.56","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"36416","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1A"},{"HCPCS_CD":"99204","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"4556.24","ALLOWED_CHARGE_AMT":"2851.44","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"2235.49","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"45990","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"44.59","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"01925","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"10102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"QS","SUBMITTED_SERVICE_CNT":"32","SUBMITTED_CHARGE_AMT":"36837.88","ALLOWED_CHARGE_AMT":"4354.89","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"32","NCH_PAYMENT_AMT":"3414.23","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"29130","HCPCS_INITIAL_MODIFIER_CD":"F8","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"30.32","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"00844","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"P2","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"588.76","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"J0690","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"44","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"76","SUBMITTED_SERVICE_CNT":"24","SUBMITTED_CHARGE_AMT":"360","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"24","DENIED_CHARGE_AMT":"360","ASSIGNED_SERVICES_CNT":"24","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"92025","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"217","SUBMITTED_CHARGE_AMT":"15763.92","ALLOWED_CHARGE_AMT":"7370.63","DENIED_SERVICES_CNT":"30","DENIED_CHARGE_AMT":"2134.94","ASSIGNED_SERVICES_CNT":"217","NCH_PAYMENT_AMT":"5496.15","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"J9202","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"09202","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"125","SUBMITTED_CHARGE_AMT":"28033.07","ALLOWED_CHARGE_AMT":"24991.35","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"125","NCH_PAYMENT_AMT":"18986.09","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"O1D"},{"HCPCS_CD":"74330","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"174","SUBMITTED_CHARGE_AMT":"30970.75","ALLOWED_CHARGE_AMT":"7495.67","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"174","NCH_PAYMENT_AMT":"5870.89","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1D"},{"HCPCS_CD":"G0438","HCPCS_INITIAL_MODIFIER_CD":"CC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"67820","HCPCS_INITIAL_MODIFIER_CD":"E1","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"36246","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"105.49","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"61","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"30.19","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"65222","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"45.09","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"01630","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"805.34","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"L2780","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"55","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"42","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"23","SUBMITTED_CHARGE_AMT":"1480.98","ALLOWED_CHARGE_AMT":"1077.46","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"23","NCH_PAYMENT_AMT":"844.72","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"11643","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"175.55","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"22901","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"665.75","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"41112","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"85","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"995.4","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"32505","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1501.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"77002","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"D4","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"21.07","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"28111","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"283.46","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"G8484","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"K0827","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"41","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KI","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1857.2","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"67904","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"489.75","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"23500","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"44","SUBMITTED_CHARGE_AMT":"20772","ALLOWED_CHARGE_AMT":"8234.38","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"44","NCH_PAYMENT_AMT":"6119.09","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"87480","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"107.24","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"28122","HCPCS_INITIAL_MODIFIER_CD":"T9","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"765.14","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"76942","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"J7","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"25.31","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3F"},{"HCPCS_CD":"28043","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"98.51","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"99309","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"89","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"789","SUBMITTED_CHARGE_AMT":"85237","ALLOWED_CHARGE_AMT":"56970.93","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"789","NCH_PAYMENT_AMT":"39475","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"67145","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2384.02","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4C"},{"HCPCS_CD":"J1040","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"14.21","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"106.82","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"37227","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1805.52","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"92014","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"3222","ALLOWED_CHARGE_AMT":"1564.56","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"1226.7","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5C"},{"HCPCS_CD":"32550","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"179.35","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"99222","HCPCS_INITIAL_MODIFIER_CD":"PD","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"103.59","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"93612","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"792.72","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"90472","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"17","SUBMITTED_CHARGE_AMT":"387.82","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"17","DENIED_CHARGE_AMT":"387.82","ASSIGNED_SERVICES_CNT":"17","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1G"},{"HCPCS_CD":"44388","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"893.25","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8D"},{"HCPCS_CD":"94729","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"412","SUBMITTED_CHARGE_AMT":"16812.5","ALLOWED_CHARGE_AMT":"3543.03","DENIED_SERVICES_CNT":"19","DENIED_CHARGE_AMT":"754.25","ASSIGNED_SERVICES_CNT":"412","NCH_PAYMENT_AMT":"2731.38","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"27524","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"90.85","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"76942","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"D6","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"576.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3F"},{"HCPCS_CD":"33010","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"109.7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"57421","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"98","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"46.07","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"62284","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"137.62","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"33534","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"897.13","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2A"},{"HCPCS_CD":"28400","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"429.44","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"72070","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"Q6","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"40.84","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"82271","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"4.35","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"11622","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"115.97","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"89060","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"Q5","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"14.37","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"37236","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"19","SUBMITTED_CHARGE_AMT":"145923","ALLOWED_CHARGE_AMT":"7686.08","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"19","NCH_PAYMENT_AMT":"5772.19","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2B"},{"HCPCS_CD":"35661","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"891.03","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"97110","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GV","SUBMITTED_SERVICE_CNT":"116","SUBMITTED_CHARGE_AMT":"6380","ALLOWED_CHARGE_AMT":"2940.76","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"116","NCH_PAYMENT_AMT":"2245.44","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"L2330","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"23","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"271.44","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"34111","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"33.92","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"E0112","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"99","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"26.96","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"70491","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"53","SUBMITTED_CHARGE_AMT":"9766.25","ALLOWED_CHARGE_AMT":"3515.5","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"53","NCH_PAYMENT_AMT":"2723.86","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2A"},{"HCPCS_CD":"36410","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"1374","ALLOWED_CHARGE_AMT":"171.68","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"126.15","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"73630","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"G9","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"13.22","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"93010","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"19.83","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2A"},{"HCPCS_CD":"11301","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"254.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"35372","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"53.57","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"17000","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"14","SUBMITTED_CHARGE_AMT":"1511.67","ALLOWED_CHARGE_AMT":"910.34","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"14","NCH_PAYMENT_AMT":"658.48","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"19086","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"153.41","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1A"},{"HCPCS_CD":"20550","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"51.71","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"64416","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"129","SUBMITTED_CHARGE_AMT":"220234","ALLOWED_CHARGE_AMT":"10286.02","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"129","NCH_PAYMENT_AMT":"7955.73","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"77002","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"72141","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"48","SUBMITTED_CHARGE_AMT":"52812","ALLOWED_CHARGE_AMT":"8642.83","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"48","NCH_PAYMENT_AMT":"6775.99","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2D"},{"HCPCS_CD":"L5668","HCPCS_INITIAL_MODIFIER_CD":"K3","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"10","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"1598.88","ALLOWED_CHARGE_AMT":"1053.42","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"825.87","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"84075","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"8.68","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"73140","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"F5","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"11.5","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"82985","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"16","SUBMITTED_CHARGE_AMT":"864","ALLOWED_CHARGE_AMT":"328.96","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"16","NCH_PAYMENT_AMT":"322.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"11101","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"128.05","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"88305","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"434","SUBMITTED_CHARGE_AMT":"94725","ALLOWED_CHARGE_AMT":"12457.4","DENIED_SERVICES_CNT":"121","DENIED_CHARGE_AMT":"26279.5","ASSIGNED_SERVICES_CNT":"434","NCH_PAYMENT_AMT":"9674.35","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"36561","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"37","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"328.05","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8F"},{"HCPCS_CD":"58150","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"126","SUBMITTED_CHARGE_AMT":"341338.31","ALLOWED_CHARGE_AMT":"116806.01","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"126","NCH_PAYMENT_AMT":"87575.72","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1E"},{"HCPCS_CD":"36475","HCPCS_INITIAL_MODIFIER_CD":"53","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"43.18","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"27822","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"612.51","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"98926","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"13","SUBMITTED_CHARGE_AMT":"1070","ALLOWED_CHARGE_AMT":"484.33","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"13","NCH_PAYMENT_AMT":"319.48","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"73590","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"119","SUBMITTED_CHARGE_AMT":"10225.92","ALLOWED_CHARGE_AMT":"2839.15","DENIED_SERVICES_CNT":"29","DENIED_CHARGE_AMT":"3436","ASSIGNED_SERVICES_CNT":"119","NCH_PAYMENT_AMT":"2023.89","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"70540","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"426.06","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2C"},{"HCPCS_CD":"27301","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"344.67","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"72125","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"J5","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"176.17","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"44","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"246.66","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"17250","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"68","SUBMITTED_CHARGE_AMT":"7262.4","ALLOWED_CHARGE_AMT":"4202.88","DENIED_SERVICES_CNT":"20","DENIED_CHARGE_AMT":"2136","ASSIGNED_SERVICES_CNT":"68","NCH_PAYMENT_AMT":"3254.48","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"26540","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"FA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"509.82","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"12052","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"347.04","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"2929","SUBMITTED_CHARGE_AMT":"461311","ALLOWED_CHARGE_AMT":"151011.98","DENIED_SERVICES_CNT":"121","DENIED_CHARGE_AMT":"17114","ASSIGNED_SERVICES_CNT":"2929","NCH_PAYMENT_AMT":"112324.01","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"L4205","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"GY","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"16.98","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"29445","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"3000","ALLOWED_CHARGE_AMT":"1525.35","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"1195.8","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"33241","HCPCS_INITIAL_MODIFIER_CD":"Q0","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"253.71","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2E"},{"HCPCS_CD":"30118","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"672.41","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"A6457","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"67","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1A"},{"HCPCS_CD":"11044","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"73110","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"76","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"37.95","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"G8536","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"4751","SUBMITTED_CHARGE_AMT":"0","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"4751","DENIED_CHARGE_AMT":"0","ASSIGNED_SERVICES_CNT":"4751","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"L5624","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"44","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"K2","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1071","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"L5624","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"49","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"K2","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1193.36","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"171.64","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C0","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"22","SUBMITTED_CHARGE_AMT":"1713.36","ALLOWED_CHARGE_AMT":"593.34","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"22","NCH_PAYMENT_AMT":"423","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"5","BETOS_CD":"M1B"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"1831","SUBMITTED_CHARGE_AMT":"333946.69","ALLOWED_CHARGE_AMT":"166456.44","DENIED_SERVICES_CNT":"127","DENIED_CHARGE_AMT":"24282.69","ASSIGNED_SERVICES_CNT":"1831","NCH_PAYMENT_AMT":"128393","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"70260","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"25.71","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"17250","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"57.48","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"38700","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1275.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"47100","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"13","SUBMITTED_CHARGE_AMT":"25079.78","ALLOWED_CHARGE_AMT":"5615.11","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"13","NCH_PAYMENT_AMT":"4402.2","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"71270","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"227.58","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"50389","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"41.95","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"50592","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"869.1","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"2026F","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"31","SUBMITTED_CHARGE_AMT":"0","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"31","DENIED_CHARGE_AMT":"0","ASSIGNED_SERVICES_CNT":"31","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"15830","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"97813","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"825","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"825","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"E0100","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"289","SUBMITTED_CHARGE_AMT":"9021.46","ALLOWED_CHARGE_AMT":"5716.7","DENIED_SERVICES_CNT":"26","DENIED_CHARGE_AMT":"999.54","ASSIGNED_SERVICES_CNT":"289","NCH_PAYMENT_AMT":"4123.26","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"67921","HCPCS_INITIAL_MODIFIER_CD":"SG","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1266.04","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"G9196","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5B"},{"HCPCS_CD":"28750","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"455.33","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"36226","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"849.04","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"65.25","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"A4358","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"33","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"28810","HCPCS_INITIAL_MODIFIER_CD":"T4","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"668.86","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"69210","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"25.49","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"93880","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"GV","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"47.1","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3D"},{"HCPCS_CD":"68320","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"648.57","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"86812","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"60","SUBMITTED_CHARGE_AMT":"960","ALLOWED_CHARGE_AMT":"912","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"60","NCH_PAYMENT_AMT":"879.44","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"86235","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"39","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"CB","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"2843.88","ALLOWED_CHARGE_AMT":"293.52","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"287.64","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"99236","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"83695","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"17.31","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"70486","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"36","CARRIER_NUM":"10102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"261.54","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2A"},{"HCPCS_CD":"00160","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"P3","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"158.18","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"26123","HCPCS_INITIAL_MODIFIER_CD":"F4","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1856.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"73080","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"25.28","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"32551","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"135.02","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"99305","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"109.03","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"69100","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"194.31","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"37226","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"214.86","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"77057","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"52","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"212.15","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1A"},{"HCPCS_CD":"54065","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"161.56","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"473","SUBMITTED_CHARGE_AMT":"31437.08","ALLOWED_CHARGE_AMT":"11466.67","DENIED_SERVICES_CNT":"15","DENIED_CHARGE_AMT":"1029.22","ASSIGNED_SERVICES_CNT":"473","NCH_PAYMENT_AMT":"8436.91","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"17311","HCPCS_INITIAL_MODIFIER_CD":"73","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"737.8","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"108","SUBMITTED_CHARGE_AMT":"22899.63","ALLOWED_CHARGE_AMT":"9172.71","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"2000.12","ASSIGNED_SERVICES_CNT":"108","NCH_PAYMENT_AMT":"6225.36","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"73560","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"6.47","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"69210","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"184.67","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"317.76","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"63.03","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"93880","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"387","SUBMITTED_CHARGE_AMT":"69233.88","ALLOWED_CHARGE_AMT":"10944.06","DENIED_SERVICES_CNT":"29","DENIED_CHARGE_AMT":"4864","ASSIGNED_SERVICES_CNT":"387","NCH_PAYMENT_AMT":"8381.42","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3D"},{"HCPCS_CD":"20005","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"82","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"177.64","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"43239","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"279.95","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8B"},{"HCPCS_CD":"J0696","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"230","ALLOWED_CHARGE_AMT":"10.33","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"8.11","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"8583","SUBMITTED_CHARGE_AMT":"952223.32","ALLOWED_CHARGE_AMT":"373966.11","DENIED_SERVICES_CNT":"1133","DENIED_CHARGE_AMT":"103931.65","ASSIGNED_SERVICES_CNT":"8582","NCH_PAYMENT_AMT":"273251.23","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"99350","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"437.54","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4A"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"39.69","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"99387","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"224","SUBMITTED_CHARGE_AMT":"47297.46","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"224","DENIED_CHARGE_AMT":"47297.46","ASSIGNED_SERVICES_CNT":"220","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"11740","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"36.75","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"67031","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"469.67","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"99222","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"51","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"866","SUBMITTED_CHARGE_AMT":"191541.86","ALLOWED_CHARGE_AMT":"92243.58","DENIED_SERVICES_CNT":"39","DENIED_CHARGE_AMT":"8260.19","ASSIGNED_SERVICES_CNT":"866","NCH_PAYMENT_AMT":"70406.09","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"36222","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"989.28","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"36228","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"177.71","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"11423","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"71275","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"35","SUBMITTED_CHARGE_AMT":"9453","ALLOWED_CHARGE_AMT":"3149.52","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"35","NCH_PAYMENT_AMT":"2362.21","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"94660","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"76","SUBMITTED_CHARGE_AMT":"16340","ALLOWED_CHARGE_AMT":"3098.25","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"76","NCH_PAYMENT_AMT":"2332.08","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"19380","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"616.22","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1A"},{"HCPCS_CD":"80171","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"31","SUBMITTED_CHARGE_AMT":"4155.56","ALLOWED_CHARGE_AMT":"524.61","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"31","NCH_PAYMENT_AMT":"514.17","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"20680","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"689.76","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"A5120","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"140.3","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"15","DENIED_CHARGE_AMT":"140.3","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"70491","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"127.58","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2A"},{"HCPCS_CD":"11720","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"107.64","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"28308","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"T6","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"144.38","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"99232","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"57","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"115.14","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"129.65","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"93005","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"7.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2A"},{"HCPCS_CD":"95806","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"52","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"142.05","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"70486","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"504","SUBMITTED_CHARGE_AMT":"120130","ALLOWED_CHARGE_AMT":"28280.2","DENIED_SERVICES_CNT":"20","DENIED_CHARGE_AMT":"4717","ASSIGNED_SERVICES_CNT":"504","NCH_PAYMENT_AMT":"20780.55","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2A"},{"HCPCS_CD":"36200","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"63.91","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"75574","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"10102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"162","SUBMITTED_CHARGE_AMT":"54270","ALLOWED_CHARGE_AMT":"17616.06","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"162","NCH_PAYMENT_AMT":"13698.7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"73600","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"479","ALLOWED_CHARGE_AMT":"219.82","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"161.79","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"10140","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"227.61","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"72157","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"442.65","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2D"},{"HCPCS_CD":"47000","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"477.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"26850","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"247.1","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"53230","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"532.08","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"64455","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.97","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"34826","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"158.19","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"65778","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"44","SUBMITTED_CHARGE_AMT":"93477","ALLOWED_CHARGE_AMT":"51019.74","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"44","NCH_PAYMENT_AMT":"39999.5","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"30905","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"92.34","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"L5629","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"702.15","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"72125","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"68.31","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"19307","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"91","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3594.68","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1A"},{"HCPCS_CD":"Q2037","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"417","SUBMITTED_CHARGE_AMT":"10441.77","ALLOWED_CHARGE_AMT":"5430.99","DENIED_SERVICES_CNT":"23","DENIED_CHARGE_AMT":"746.34","ASSIGNED_SERVICES_CNT":"417","NCH_PAYMENT_AMT":"5306.62","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1G"},{"HCPCS_CD":"69930","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"946.78","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"90791","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"89","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"4572","ALLOWED_CHARGE_AMT":"1965.96","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"1541.34","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5B"},{"HCPCS_CD":"29540","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"497.2","ALLOWED_CHARGE_AMT":"212.41","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"166.54","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"92933","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LD","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1092.2","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2D"},{"HCPCS_CD":"11310","HCPCS_INITIAL_MODIFIER_CD":"E2","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"13292","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"104.39","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"25608","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"17","SUBMITTED_CHARGE_AMT":"38864.22","ALLOWED_CHARGE_AMT":"14229.57","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"17","NCH_PAYMENT_AMT":"11010.65","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"73030","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"22.38","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"29700","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"13132","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1512.42","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"22015","HCPCS_INITIAL_MODIFIER_CD":"82","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"78","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"56420","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"20","SUBMITTED_CHARGE_AMT":"7642","ALLOWED_CHARGE_AMT":"2329.49","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"20","NCH_PAYMENT_AMT":"1826.32","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"11055","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"Q9","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"224.57","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"50688","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"627.2","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"43276","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"797.14","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8B"},{"HCPCS_CD":"86682","HCPCS_INITIAL_MODIFIER_CD":"91","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"17.39","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"00930","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"67.04","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"117.5","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"K0003","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"53","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KJ","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"1275.92","ALLOWED_CHARGE_AMT":"323.96","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"196.39","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"L0637","HCPCS_INITIAL_MODIFIER_CD":"RA","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"775.2","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"J0585","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"600","SUBMITTED_CHARGE_AMT":"4200","ALLOWED_CHARGE_AMT":"3255","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"600","NCH_PAYMENT_AMT":"2551.92","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"R0076","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"28045","HCPCS_INITIAL_MODIFIER_CD":"T5","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"158.44","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"99222","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"44","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"99495","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"83.18","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"11400","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"147.51","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"25","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"98.46","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"L1970","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"97014","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"49","SUBMITTED_CHARGE_AMT":"1260","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"49","DENIED_CHARGE_AMT":"1260","ASSIGNED_SERVICES_CNT":"49","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"G9172","HCPCS_INITIAL_MODIFIER_CD":"GN","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CI","SUBMITTED_SERVICE_CNT":"101","SUBMITTED_CHARGE_AMT":"7.06","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"101","DENIED_CHARGE_AMT":"7.06","ASSIGNED_SERVICES_CNT":"101","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"94060","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"E3","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"93971","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"152.8","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3F"},{"HCPCS_CD":"69610","HCPCS_INITIAL_MODIFIER_CD":"SG","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"155.57","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"G8982","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"CM","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"65855","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"49","SUBMITTED_CHARGE_AMT":"43572.55","ALLOWED_CHARGE_AMT":"15907.69","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"49","NCH_PAYMENT_AMT":"12406.4","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"78315","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"36","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"126.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1E"},{"HCPCS_CD":"1123F","HCPCS_INITIAL_MODIFIER_CD":"8P","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"116","SUBMITTED_CHARGE_AMT":"0","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"116","DENIED_CHARGE_AMT":"0","ASSIGNED_SERVICES_CNT":"116","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"35286","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"80","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"148.82","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"01214","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"32","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"QS","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"305.98","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"E1392","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"A0","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"40.47","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1C"},{"HCPCS_CD":"10022","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"109.67","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6D"},{"HCPCS_CD":"91035","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"G0105","HCPCS_INITIAL_MODIFIER_CD":"53","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"254.64","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8D"},{"HCPCS_CD":"35471","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"213.78","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"73060","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"180.92","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"76705","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"537.42","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I3B"},{"HCPCS_CD":"28313","HCPCS_INITIAL_MODIFIER_CD":"T2","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"144.14","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"20553","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"3734","ALLOWED_CHARGE_AMT":"351.49","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"275.53","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"27340","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"147.45","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"64413","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"09202","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"54.95","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"22612","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"79","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"93567","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"32","SUBMITTED_CHARGE_AMT":"5557.92","ALLOWED_CHARGE_AMT":"1468.48","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"32","NCH_PAYMENT_AMT":"1151.36","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"73130","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"20.88","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"11057","HCPCS_INITIAL_MODIFIER_CD":"Q8","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"33","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"248","SUBMITTED_CHARGE_AMT":"17475.3","ALLOWED_CHARGE_AMT":"14916","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"248","NCH_PAYMENT_AMT":"10946.75","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"73620","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"78","SUBMITTED_CHARGE_AMT":"5604","ALLOWED_CHARGE_AMT":"2019.76","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"78","NCH_PAYMENT_AMT":"1369.4","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"12042","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"105.87","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"29240","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"681.58","ALLOWED_CHARGE_AMT":"106.16","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"83.22","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"84443","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"42","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"531","ALLOWED_CHARGE_AMT":"137.58","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"115.34","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"L5704","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"57","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"64450","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"90.81","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"49653","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"688.87","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8I"},{"HCPCS_CD":"L3760","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"52","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"34","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1353.23","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"64635","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"176.86","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"53665","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"30.36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"99396","HCPCS_INITIAL_MODIFIER_CD":"52","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GY","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"94761","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"27487","HCPCS_INITIAL_MODIFIER_CD":"52","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3864","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"73610","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"550","ALLOWED_CHARGE_AMT":"359.9","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"254.38","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"99253","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"3","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M6"},{"HCPCS_CD":"82550","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"69.6","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"26445","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"F6","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"198.76","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"99222","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"103.59","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"84443","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"13292","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"67.41","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"85060","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"62365","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"168.92","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"99202","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"76.56","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"17262","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"230.96","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"L5679","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"387.91","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"Q0091","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"43.27","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"E2211","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"A0","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RB","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"92.83","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"73590","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"7.34","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"A4310","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"10","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"36","SUBMITTED_CHARGE_AMT":"353.91","ALLOWED_CHARGE_AMT":"250.95","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"36","NCH_PAYMENT_AMT":"185.74","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"A5512","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"55","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"J","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"242","SUBMITTED_CHARGE_AMT":"8466.2","ALLOWED_CHARGE_AMT":"6692.96","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"242","NCH_PAYMENT_AMT":"5164.16","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"36514","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"510.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"22220","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"577.91","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"64483","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"159","SUBMITTED_CHARGE_AMT":"140157","ALLOWED_CHARGE_AMT":"17167.36","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"159","NCH_PAYMENT_AMT":"13336.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"G0127","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"Q7","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"34.46","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"35476","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"14512","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"214.76","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"L3760","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"338.31","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"E2213","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"13.1","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"73140","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"23","SUBMITTED_CHARGE_AMT":"1755.75","ALLOWED_CHARGE_AMT":"504.64","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"23","NCH_PAYMENT_AMT":"312.3","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"00740","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"3170F","HCPCS_INITIAL_MODIFIER_CD":"8P","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"99205","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1159.73","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"11402","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"39.81","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"J7324","HCPCS_INITIAL_MODIFIER_CD":"EJ","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"18","SUBMITTED_CHARGE_AMT":"6346","ALLOWED_CHARGE_AMT":"3294.64","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"18","NCH_PAYMENT_AMT":"2583","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"26020","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"356.86","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"67331","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P4E"},{"HCPCS_CD":"49560","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"6328.49","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"12031","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"87.24","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"31623","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"81","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"116.47","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8F"},{"HCPCS_CD":"L2232","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"57","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"143.62","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"121.13","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"73140","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"94729","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"39.5","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"27486","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1053.67","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"45380","HCPCS_INITIAL_MODIFIER_CD":"52","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"35.03","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8D"},{"HCPCS_CD":"90847","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"68","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5B"},{"HCPCS_CD":"82962","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"12","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3.14","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1E"},{"HCPCS_CD":"11721","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"71.98","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"G8979","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CK","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"81001","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"21.15","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1C"},{"HCPCS_CD":"43255","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"81.54","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8B"},{"HCPCS_CD":"76998","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"28","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"305.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3F"},{"HCPCS_CD":"V2100","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"96","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"23","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"VP","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"31.36","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"47500","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"306.4","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"73050","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"28.29","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"11100","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"417.8","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"G8127","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"26","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"93660","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"185","SUBMITTED_CHARGE_AMT":"137570.67","ALLOWED_CHARGE_AMT":"17043.05","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"185","NCH_PAYMENT_AMT":"12982.39","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"J7613","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"03","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0.34","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1G"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"2796.98","ALLOWED_CHARGE_AMT":"1038.93","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"737.11","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"47525","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"297.18","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"20520","HCPCS_INITIAL_MODIFIER_CD":"F6","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"55.62","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"72148","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"8.34","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2D"},{"HCPCS_CD":"65756","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"65","SUBMITTED_CHARGE_AMT":"217460.24","ALLOWED_CHARGE_AMT":"70189.62","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"62","NCH_PAYMENT_AMT":"54768.85","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4A"},{"HCPCS_CD":"28062","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"352.51","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"A4558","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"87273","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"99202","HCPCS_INITIAL_MODIFIER_CD":"CC","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"25","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"61.39","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"36558","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"198","SUBMITTED_CHARGE_AMT":"360606","ALLOWED_CHARGE_AMT":"56005.88","DENIED_SERVICES_CNT":"24","DENIED_CHARGE_AMT":"37209","ASSIGNED_SERVICES_CNT":"198","NCH_PAYMENT_AMT":"43191.2","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"L0472","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"44","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2726.08","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"26055","HCPCS_INITIAL_MODIFIER_CD":"F9","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"123.3","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"L0472","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"257.94","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"35876","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"379.5","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"4005F","HCPCS_INITIAL_MODIFIER_CD":"8P","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"43236","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1593.8","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8B"},{"HCPCS_CD":"99219","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"106.88","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"53200","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"98","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"113.47","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"G8978","HCPCS_INITIAL_MODIFIER_CD":"CK","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"GP","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"0.1","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"11","DENIED_CHARGE_AMT":"0.1","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"76376","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"82306","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"127.85","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"15823","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"50","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1110.12","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"36245","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"73","SUBMITTED_CHARGE_AMT":"66577","ALLOWED_CHARGE_AMT":"9745.62","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"73","NCH_PAYMENT_AMT":"7640.59","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"G0202","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"B9","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"1605","ALLOWED_CHARGE_AMT":"493.22","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"483.42","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1C"},{"HCPCS_CD":"29915","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"324.08","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8A"},{"HCPCS_CD":"L2220","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"B3","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"120.79","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"77052","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"49","SUBMITTED_CHARGE_AMT":"490","ALLOWED_CHARGE_AMT":"307.68","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"49","NCH_PAYMENT_AMT":"301.44","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1A"},{"HCPCS_CD":"92979","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LD","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"54.53","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I3C"},{"HCPCS_CD":"15777","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"34812","HCPCS_INITIAL_MODIFIER_CD":"62","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"11402","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"100.3","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"22610","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"30","SUBMITTED_CHARGE_AMT":"68523.03","ALLOWED_CHARGE_AMT":"3646.06","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"30","NCH_PAYMENT_AMT":"2791.26","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"81321","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"9000","ALLOWED_CHARGE_AMT":"600","DENIED_SERVICES_CNT":"14","DENIED_CHARGE_AMT":"8400","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"588","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"74170","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"170.68","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"80053","HCPCS_INITIAL_MODIFIER_CD":"CC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"33.15","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1B"},{"HCPCS_CD":"G0415","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"58","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1048.32","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"93227","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"207","SUBMITTED_CHARGE_AMT":"16957.21","ALLOWED_CHARGE_AMT":"5166.97","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"207","NCH_PAYMENT_AMT":"3857.71","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2C"},{"HCPCS_CD":"G8989","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"67","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CI","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"22522","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"172.58","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"71250","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"260.18","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2B"},{"HCPCS_CD":"G0268","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"14512","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"24","SUBMITTED_CHARGE_AMT":"2160","ALLOWED_CHARGE_AMT":"1184.76","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"24","NCH_PAYMENT_AMT":"783.87","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"L1970","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"511.71","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"J7321","HCPCS_INITIAL_MODIFIER_CD":"EJ","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"148","SUBMITTED_CHARGE_AMT":"120472","ALLOWED_CHARGE_AMT":"13182.82","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"148","NCH_PAYMENT_AMT":"10269.56","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"99236","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"314.42","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"31575","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"41","SUBMITTED_CHARGE_AMT":"10062.48","ALLOWED_CHARGE_AMT":"4315.31","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"41","NCH_PAYMENT_AMT":"3204.81","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8H"},{"HCPCS_CD":"93452","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1148.18","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"86622","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"12032","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"17","SUBMITTED_CHARGE_AMT":"7310","ALLOWED_CHARGE_AMT":"4760.34","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"17","NCH_PAYMENT_AMT":"3501.68","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"99347","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"261.1","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4A"},{"HCPCS_CD":"93923","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"53","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"8.37","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"29505","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"110.7","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"33249","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"Q0","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"889.3","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2E"},{"HCPCS_CD":"73610","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"376","SUBMITTED_CHARGE_AMT":"19617.41","ALLOWED_CHARGE_AMT":"3154.04","DENIED_SERVICES_CNT":"13","DENIED_CHARGE_AMT":"661","ASSIGNED_SERVICES_CNT":"376","NCH_PAYMENT_AMT":"2202.84","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"63655","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"346.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"A7525","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"GA","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"50650","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"771.66","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"11042","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"78","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"96.44","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"00810","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"G8","SUBMITTED_SERVICE_CNT":"23","SUBMITTED_CHARGE_AMT":"44872","ALLOWED_CHARGE_AMT":"747.96","DENIED_SERVICES_CNT":"19","DENIED_CHARGE_AMT":"38626","ASSIGNED_SERVICES_CNT":"23","NCH_PAYMENT_AMT":"586.41","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"23474","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2807.04","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P3D"},{"HCPCS_CD":"74022","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"78.91","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"29515","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"203.34","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"L1832","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"560.38","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"L2230","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"42","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"53.05","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"79","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"54.29","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"26055","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1233","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"52000","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"133.21","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8E"},{"HCPCS_CD":"67113","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2942.98","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4C"},{"HCPCS_CD":"67875","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"803.4","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"64495","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"66.56","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"K0848","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"24","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3843.11","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1D"},{"HCPCS_CD":"A4466","HCPCS_INITIAL_MODIFIER_CD":"CG","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"9","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"80048","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"50","SUBMITTED_CHARGE_AMT":"3117","ALLOWED_CHARGE_AMT":"559.91","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"50","NCH_PAYMENT_AMT":"529.09","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1B"},{"HCPCS_CD":"64484","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"10","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"99335","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"17","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"317.04","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"26010","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"224.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"L1810","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"371.29","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"20225","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"10202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"171.4","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"J2690","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"O1E"},{"HCPCS_CD":"13101","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"737.84","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"15260","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"28308","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"151.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"26480","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"99235","HCPCS_INITIAL_MODIFIER_CD":"AI","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"282.68","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"64450","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"45381","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"104","SUBMITTED_CHARGE_AMT":"79678","ALLOWED_CHARGE_AMT":"2909.28","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"104","NCH_PAYMENT_AMT":"2258.5","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8D"},{"HCPCS_CD":"11055","HCPCS_INITIAL_MODIFIER_CD":"Q8","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"T1","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"36.81","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"92250","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"J7","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"126","SUBMITTED_CHARGE_AMT":"13788.11","ALLOWED_CHARGE_AMT":"7577.1","DENIED_SERVICES_CNT":"15","DENIED_CHARGE_AMT":"1825","ASSIGNED_SERVICES_CNT":"126","NCH_PAYMENT_AMT":"5705.57","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5C"},{"HCPCS_CD":"45130","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2520.18","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"A4624","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"B3","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"934","SUBMITTED_CHARGE_AMT":"3303.34","ALLOWED_CHARGE_AMT":"2684.16","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"934","NCH_PAYMENT_AMT":"2104.3","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"64611","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"52","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"11.65","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"52332","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"3032.13","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8E"},{"HCPCS_CD":"L5590","HCPCS_INITIAL_MODIFIER_CD":"K3","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"4137.88","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"32608","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"299.62","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"72070","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"21.04","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"76857","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"628","SUBMITTED_CHARGE_AMT":"126235.38","ALLOWED_CHARGE_AMT":"24750.11","DENIED_SERVICES_CNT":"205","DENIED_CHARGE_AMT":"34914.26","ASSIGNED_SERVICES_CNT":"628","NCH_PAYMENT_AMT":"19192.04","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I3B"},{"HCPCS_CD":"11012","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"343.86","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"70551","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"43.36","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2C"},{"HCPCS_CD":"11402","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"91","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"12032","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"12042","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"81.4","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"33241","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"182.74","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P2E"},{"HCPCS_CD":"73560","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"G4","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"23.29","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"12042","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"99244","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"3","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M6"},{"HCPCS_CD":"26600","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"422.2","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6B"},{"HCPCS_CD":"65756","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"714.32","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P4A"},{"HCPCS_CD":"99232","HCPCS_INITIAL_MODIFIER_CD":"CC","PROVIDER_SPEC_CD":"26","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"183.39","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"87621","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"26","SUBMITTED_CHARGE_AMT":"1922","ALLOWED_CHARGE_AMT":"765.92","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"26","NCH_PAYMENT_AMT":"750.56","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"0311T","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"99233","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"77","SUBMITTED_CHARGE_AMT":"15031.6","ALLOWED_CHARGE_AMT":"7414.84","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"77","NCH_PAYMENT_AMT":"5812.99","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2B"},{"HCPCS_CD":"61616","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2447.7","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"11624","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"182.75","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"36470","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"54.17","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"96372","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"48","SUBMITTED_CHARGE_AMT":"2264.71","ALLOWED_CHARGE_AMT":"1156.03","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"48","NCH_PAYMENT_AMT":"841.42","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"36558","HCPCS_INITIAL_MODIFIER_CD":"53","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"219.88","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"A7037","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"21.98","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"L4386","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"55","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"37761","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"17400","ALLOWED_CHARGE_AMT":"4435.8","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"3477.75","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"91.38","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"L2755","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"17003","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"193.2","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"26055","HCPCS_INITIAL_MODIFIER_CD":"F9","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"504.6","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"74000","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"36","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"11","SUBMITTED_CHARGE_AMT":"341","ALLOWED_CHARGE_AMT":"102.74","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"11","NCH_PAYMENT_AMT":"80.52","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1F"},{"HCPCS_CD":"L3908","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"99292","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"Q6","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"182.64","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"G8981","HCPCS_INITIAL_MODIFIER_CD":"CL","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GP","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"12001","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"10102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"Q6","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"33.5","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"99223","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"AQ","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"477.51","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2A"},{"HCPCS_CD":"77413","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"57","SUBMITTED_CHARGE_AMT":"28215","ALLOWED_CHARGE_AMT":"11569.29","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"57","NCH_PAYMENT_AMT":"9070.41","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P7A"},{"HCPCS_CD":"57415","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"130.11","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"93279","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"34.24","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2C"},{"HCPCS_CD":"L0637","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"A6","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"27","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"2134.94","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"42440","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"783","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"99204","HCPCS_INITIAL_MODIFIER_CD":"GT","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"688.5","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1A"},{"HCPCS_CD":"73530","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"D1","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"11.58","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"92235","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"291.58","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5C"},{"HCPCS_CD":"01444","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"351.53","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"00860","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"22","SUBMITTED_CHARGE_AMT":"19150","ALLOWED_CHARGE_AMT":"4096.36","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"22","NCH_PAYMENT_AMT":"3211.54","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"K0730","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"16003","PRICING_LOCALITY_CD":"22","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"295.6","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"L3510","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"10302","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"19285","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1A"},{"HCPCS_CD":"76000","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"5.78","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"I4B"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"GW","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"52.19","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"63056","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"646.98","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1F"},{"HCPCS_CD":"93281","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"85.55","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2C"},{"HCPCS_CD":"11302","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"94.93","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"61107","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"73723","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"876.49","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I2D"},{"HCPCS_CD":"95810","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"49","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"16","SUBMITTED_CHARGE_AMT":"3200","ALLOWED_CHARGE_AMT":"1328.8","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"16","NCH_PAYMENT_AMT":"1041.81","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"25","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"822.2","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"87493","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"59430","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"94","SUBMITTED_CHARGE_AMT":"22961.46","ALLOWED_CHARGE_AMT":"13538.01","DENIED_SERVICES_CNT":"15","DENIED_CHARGE_AMT":"4218","ASSIGNED_SERVICES_CNT":"94","NCH_PAYMENT_AMT":"10068.17","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M5D"},{"HCPCS_CD":"00862","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"236","SUBMITTED_CHARGE_AMT":"334078.78","ALLOWED_CHARGE_AMT":"52828.05","DENIED_SERVICES_CNT":"12","DENIED_CHARGE_AMT":"14497.31","ASSIGNED_SERVICES_CNT":"236","NCH_PAYMENT_AMT":"41307.39","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"99309","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"375.19","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M4B"},{"HCPCS_CD":"95979","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"67.75","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"97597","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"18.91","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"96360","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"188.1","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P6C"},{"HCPCS_CD":"95887","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"27620","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"59","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"371.1","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"63044","HCPCS_INITIAL_MODIFIER_CD":"62","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"257.81","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P1F"},{"HCPCS_CD":"0517F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"858","SUBMITTED_CHARGE_AMT":"2.82","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"858","DENIED_CHARGE_AMT":"2.82","ASSIGNED_SERVICES_CNT":"858","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"Z2"},{"HCPCS_CD":"87880","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"Q6","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"16.03","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"V2020","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"9","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"88177","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"12","SUBMITTED_CHARGE_AMT":"654","ALLOWED_CHARGE_AMT":"0","DENIED_SERVICES_CNT":"12","DENIED_CHARGE_AMT":"654","ASSIGNED_SERVICES_CNT":"12","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1G"},{"HCPCS_CD":"35883","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"AS","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"203.95","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P2F"},{"HCPCS_CD":"L8699","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1F"},{"HCPCS_CD":"64771","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P1G"},{"HCPCS_CD":"15240","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"321.66","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5A"},{"HCPCS_CD":"28825","HCPCS_INITIAL_MODIFIER_CD":"T1","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"285.72","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P5B"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"46","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"341.98","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M2C"},{"HCPCS_CD":"93922","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"F6","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"15","SUBMITTED_CHARGE_AMT":"3750","ALLOWED_CHARGE_AMT":"1071.07","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"15","NCH_PAYMENT_AMT":"839.67","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T2D"},{"HCPCS_CD":"43659","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"1150.29","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P5E"},{"HCPCS_CD":"82670","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"37.36","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"31231","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"162.57","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8I"},{"HCPCS_CD":"73120","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"LT","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"6.64","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I1B"},{"HCPCS_CD":"E0141","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"45","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"78.44","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"D1E"},{"HCPCS_CD":"17250","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"98","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"175.62","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"},{"HCPCS_CD":"82575","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"37.89","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"01844","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"270.01","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"P0"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"13292","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"0","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"M1B"},{"HCPCS_CD":"84156","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"22","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"9.8","HCPCS_ASC_IND_CD":"N","ERROR_IND_CD":"0","BETOS_CD":"T1H"},{"HCPCS_CD":"76770","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"B4","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"89.1","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"I3B"},{"HCPCS_CD":"45385","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","SUBMITTED_SERVICE_CNT":"1237","SUBMITTED_CHARGE_AMT":"1566888.57","ALLOWED_CHARGE_AMT":"353133.32","DENIED_SERVICES_CNT":"28","DENIED_CHARGE_AMT":"36306.78","ASSIGNED_SERVICES_CNT":"1237","NCH_PAYMENT_AMT":"268119.38","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P8D"},{"HCPCS_CD":"15823","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","SUBMITTED_SERVICE_CNT":"","SUBMITTED_CHARGE_AMT":"","ALLOWED_CHARGE_AMT":"","DENIED_SERVICES_CNT":"","DENIED_CHARGE_AMT":"","ASSIGNED_SERVICES_CNT":"","NCH_PAYMENT_AMT":"244.04","HCPCS_ASC_IND_CD":"Y","ERROR_IND_CD":"0","BETOS_CD":"P6A"}]