[{"HCPCS_CD":"43244","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"223.93","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"93620","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"73016","PSPS_ALLOWED_CHARGE_AMT":"6553.03","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"5125.69","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"24605","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"180.57","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"20600","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"F1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"41.49","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"43239","HCPCS_INITIAL_MODIFIER_CD":"53","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"114.66","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"37200","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"182.1","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"34713","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"82","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"13.38","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"64450","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"65.8","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"G0009","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"12","PSPS_SUBMITTED_CHARGE_AMT":"393","PSPS_ALLOWED_CHARGE_AMT":"187.32","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"12","PSPS_NCH_PAYMENT_AMT":"186.7","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1G"},{"HCPCS_CD":"71250","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"98","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"Q6","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"83.83","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"36473","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"6380.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"88374","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"77","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"148.6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"96365","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"209.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"71260","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"D2","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"580.53","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"99202","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"24","PSPS_SUBMITTED_CHARGE_AMT":"2538","PSPS_ALLOWED_CHARGE_AMT":"1227.84","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"24","PSPS_NCH_PAYMENT_AMT":"954.25","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"00732","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"11441","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"78195","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"C2","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"MG","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"48.89","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1E"},{"HCPCS_CD":"74177","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"69.93","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"99211","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GV","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"21.02","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"70260","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"31.85","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"11106","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"46.14","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"17004","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"132.26","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"34111","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"418.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"82670","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"167.08","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"95","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"304.65","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"26160","HCPCS_INITIAL_MODIFIER_CD":"F2","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"126.97","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"20600","HCPCS_INITIAL_MODIFIER_CD":"T8","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"48.6","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"31622","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"27","PSPS_SUBMITTED_CHARGE_AMT":"17518.7","PSPS_ALLOWED_CHARGE_AMT":"5933.36","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"27","PSPS_NCH_PAYMENT_AMT":"4372.75","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8F"},{"HCPCS_CD":"G0289","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"489.65","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8A"},{"HCPCS_CD":"13132","HCPCS_INITIAL_MODIFIER_CD":"F6","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"F7","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"63","PSPS_SUBMITTED_CHARGE_AMT":"11804","PSPS_ALLOWED_CHARGE_AMT":"4365.36","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"63","PSPS_NCH_PAYMENT_AMT":"3390.91","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"GT","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"Q6","PSPS_SUBMITTED_SERVICE_CNT":"15","PSPS_SUBMITTED_CHARGE_AMT":"4890","PSPS_ALLOWED_CHARGE_AMT":"1173","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"15","PSPS_NCH_PAYMENT_AMT":"938.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"40490","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"17","PSPS_SUBMITTED_CHARGE_AMT":"4032.9","PSPS_ALLOWED_CHARGE_AMT":"2090.49","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"17","PSPS_NCH_PAYMENT_AMT":"1480.38","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"90785","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"80","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"95","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"9.37","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"11043","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"L4387","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"2598.77","PSPS_ALLOWED_CHARGE_AMT":"2041.88","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"1531.67","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"00811","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"X4","PSPS_SUBMITTED_SERVICE_CNT":"70","PSPS_SUBMITTED_CHARGE_AMT":"59118.91","PSPS_ALLOWED_CHARGE_AMT":"4932.48","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"70","PSPS_NCH_PAYMENT_AMT":"3956.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"3341F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"216","PSPS_SUBMITTED_CHARGE_AMT":"0.07","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"216","PSPS_DENIED_CHARGE_AMT":"0.07","PSPS_ASSIGNED_SERVICES_CNT":"216","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"A5512","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"39","TYPE_OF_SERVICE_CD":"J","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"222","PSPS_SUBMITTED_CHARGE_AMT":"10191.43","PSPS_ALLOWED_CHARGE_AMT":"6628.6","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"222","PSPS_NCH_PAYMENT_AMT":"5143.61","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"00400","HCPCS_INITIAL_MODIFIER_CD":"QY","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"XE","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"73590","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"49","HCPCS_SECOND_MODIFIER_CD":"X5","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"28.74","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"36466","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"XS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"77002","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"A4","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"43.03","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"97150","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CQ","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"95.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"75825","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"40.83","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"61312","HCPCS_INITIAL_MODIFIER_CD":"62","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1875.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"92025","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"34.13","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"L5828","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"K3","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"4509.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"L5828","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"55","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"K3","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2535.31","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"73060","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"49","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"80.07","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"28825","HCPCS_INITIAL_MODIFIER_CD":"T1","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"153.68","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"G9548","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"0","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"13","PSPS_DENIED_CHARGE_AMT":"0","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"72170","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"F6","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"27.9","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"69209","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"F8","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"75.9","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"45380","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"29","PSPS_SUBMITTED_CHARGE_AMT":"74812.75","PSPS_ALLOWED_CHARGE_AMT":"452.98","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"29","PSPS_NCH_PAYMENT_AMT":"364.86","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"71046","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"F1","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"9.07","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1A"},{"HCPCS_CD":"62355","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"226.57","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"36215","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2102.27","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"15822","HCPCS_INITIAL_MODIFIER_CD":"SG","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"311.31","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"83036","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GZ","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"73502","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"46270","HCPCS_INITIAL_MODIFIER_CD":"XS","PROVIDER_SPEC_CD":"28","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"170.28","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"64590","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"397.08","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99285","HCPCS_INITIAL_MODIFIER_CD":"CS","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"184","PSPS_SUBMITTED_CHARGE_AMT":"140552","PSPS_ALLOWED_CHARGE_AMT":"31141.1","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"184","PSPS_NCH_PAYMENT_AMT":"31440.19","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M3"},{"HCPCS_CD":"A4331","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"28010","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"387.37","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"3072F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"28","PSPS_SUBMITTED_CHARGE_AMT":"0","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"28","PSPS_DENIED_CHARGE_AMT":"0","PSPS_ASSIGNED_SERVICES_CNT":"28","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"99152","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"14512","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"19.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"91010","HCPCS_INITIAL_MODIFIER_CD":"53","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"B6","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"72.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"22315","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"344.16","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"74176","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"245.65","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"99327","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"73718","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"MH","PSPS_SUBMITTED_SERVICE_CNT":"21","PSPS_SUBMITTED_CHARGE_AMT":"4011","PSPS_ALLOWED_CHARGE_AMT":"1454.45","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"21","PSPS_NCH_PAYMENT_AMT":"1053.48","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"00731","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"P4","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"295.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"G8418","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"17","PSPS_SUBMITTED_CHARGE_AMT":"0.17","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"17","PSPS_DENIED_CHARGE_AMT":"0.17","PSPS_ASSIGNED_SERVICES_CNT":"17","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"33952","HCPCS_INITIAL_MODIFIER_CD":"XU","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"357.9","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"96127","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"95","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"45381","HCPCS_INITIAL_MODIFIER_CD":"59","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":"PT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"431.9","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"56820","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"4606","PSPS_ALLOWED_CHARGE_AMT":"1214.16","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"886.83","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"97012","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"95","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"10.66","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"19355","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"233.4","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"0191T","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"22","PSPS_SUBMITTED_CHARGE_AMT":"49669","PSPS_ALLOWED_CHARGE_AMT":"6938.72","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"22","PSPS_NCH_PAYMENT_AMT":"5587.93","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"J0696","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"9490","PSPS_SUBMITTED_CHARGE_AMT":"123693.95","PSPS_ALLOWED_CHARGE_AMT":"5165.14","PSPS_DENIED_SERVICES_CNT":"525","PSPS_DENIED_CHARGE_AMT":"7457.5","PSPS_ASSIGNED_SERVICES_CNT":"9490","PSPS_NCH_PAYMENT_AMT":"3726.86","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"03","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"63.5","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"A4452","HCPCS_INITIAL_MODIFIER_CD":"AW","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"17013","PRICING_LOCALITY_CD":"23","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"A1","PSPS_SUBMITTED_SERVICE_CNT":"602","PSPS_SUBMITTED_CHARGE_AMT":"765.5","PSPS_ALLOWED_CHARGE_AMT":"270.9","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"602","PSPS_NCH_PAYMENT_AMT":"216.72","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"11406","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":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"273.98","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"0191T","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"79","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"15000","PSPS_ALLOWED_CHARGE_AMT":"2535.12","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"2026.86","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"AI","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"76.73","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"72192","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"MF","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"43.18","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"67914","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"496.31","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"V2784","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"49","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GA","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"94664","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"125","PSPS_SUBMITTED_CHARGE_AMT":"3316.25","PSPS_ALLOWED_CHARGE_AMT":"1606.07","PSPS_DENIED_SERVICES_CNT":"18","PSPS_DENIED_CHARGE_AMT":"506","PSPS_ASSIGNED_SERVICES_CNT":"125","PSPS_NCH_PAYMENT_AMT":"1102.85","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"11719","HCPCS_INITIAL_MODIFIER_CD":"Q8","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"XS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"12.2","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"12001","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"34.05","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"70460","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"49","HCPCS_SECOND_MODIFIER_CD":"MC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"138.2","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2A"},{"HCPCS_CD":"36225","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"681.84","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"17003","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"174","PSPS_SUBMITTED_CHARGE_AMT":"1494.8","PSPS_ALLOWED_CHARGE_AMT":"373.24","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"174","PSPS_NCH_PAYMENT_AMT":"211.83","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"99284","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"489.47","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M3"},{"HCPCS_CD":"70450","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"J4","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2A"},{"HCPCS_CD":"99307","HCPCS_INITIAL_MODIFIER_CD":"GT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"104.22","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"J9228","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1737","PSPS_SUBMITTED_CHARGE_AMT":"538470","PSPS_ALLOWED_CHARGE_AMT":"256520","PSPS_DENIED_SERVICES_CNT":"97","PSPS_DENIED_CHARGE_AMT":"30070","PSPS_ASSIGNED_SERVICES_CNT":"1737","PSPS_NCH_PAYMENT_AMT":"203440.55","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1D"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"17","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"344.44","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"49553","HCPCS_INITIAL_MODIFIER_CD":"RT","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1687.24","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"73721","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"21","PSPS_SUBMITTED_CHARGE_AMT":"11540.56","PSPS_ALLOWED_CHARGE_AMT":"1374.82","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"21","PSPS_NCH_PAYMENT_AMT":"1053.44","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"E1399","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"17013","PRICING_LOCALITY_CD":"24","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"16","PSPS_SUBMITTED_CHARGE_AMT":"580","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"16","PSPS_DENIED_CHARGE_AMT":"580","PSPS_ASSIGNED_SERVICES_CNT":"16","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1E"},{"HCPCS_CD":"A6222","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"A7","PSPS_SUBMITTED_SERVICE_CNT":"140","PSPS_SUBMITTED_CHARGE_AMT":"695.8","PSPS_ALLOWED_CHARGE_AMT":"347.2","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"140","PSPS_NCH_PAYMENT_AMT":"277.76","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1A"},{"HCPCS_CD":"99442","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"531","PSPS_SUBMITTED_CHARGE_AMT":"42550.82","PSPS_ALLOWED_CHARGE_AMT":"24340.72","PSPS_DENIED_SERVICES_CNT":"34","PSPS_DENIED_CHARGE_AMT":"3206.01","PSPS_ASSIGNED_SERVICES_CNT":"531","PSPS_NCH_PAYMENT_AMT":"16175.1","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"61606","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1178.17","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"67108","HCPCS_INITIAL_MODIFIER_CD":"82","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"69847.8","PSPS_ALLOWED_CHARGE_AMT":"2074.16","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"1428.73","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4C"},{"HCPCS_CD":"15002","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"315.26","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"75710","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"70.91","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"73620","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":"11","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"131","PSPS_SUBMITTED_CHARGE_AMT":"6080","PSPS_ALLOWED_CHARGE_AMT":"1130.3","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"131","PSPS_NCH_PAYMENT_AMT":"797.59","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"21552","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"28","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"639.07","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"01965","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"265.66","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"15100","HCPCS_INITIAL_MODIFIER_CD":"58","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":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"281.05","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"76856","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"83.34","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3B"},{"HCPCS_CD":"80053","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"10.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1B"},{"HCPCS_CD":"72050","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"E5","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"39.57","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"92587","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"13292","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"K","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"21.47","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"A4467","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"51","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"47","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"31500","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"231.26","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"22853","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"374","PSPS_SUBMITTED_CHARGE_AMT":"442208","PSPS_ALLOWED_CHARGE_AMT":"88215.33","PSPS_DENIED_SERVICES_CNT":"20","PSPS_DENIED_CHARGE_AMT":"25858","PSPS_ASSIGNED_SERVICES_CNT":"374","PSPS_NCH_PAYMENT_AMT":"69983.47","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"93931","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"66.06","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3F"},{"HCPCS_CD":"99442","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GV","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"1725.5","PSPS_ALLOWED_CHARGE_AMT":"888.42","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"716.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"Q9965","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"84","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"JW","PSPS_SUBMITTED_SERVICE_CNT":"48","PSPS_SUBMITTED_CHARGE_AMT":"84.48","PSPS_ALLOWED_CHARGE_AMT":"34.46","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"48","PSPS_NCH_PAYMENT_AMT":"27.57","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1E"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"03","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"45.54","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"10081","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"128.87","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"99443","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"88","PSPS_SUBMITTED_CHARGE_AMT":"10197.16","PSPS_ALLOWED_CHARGE_AMT":"7016.05","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"88","PSPS_NCH_PAYMENT_AMT":"5173.13","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"86146","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"453","PSPS_SUBMITTED_CHARGE_AMT":"42843.72","PSPS_ALLOWED_CHARGE_AMT":"10383.6","PSPS_DENIED_SERVICES_CNT":"45","PSPS_DENIED_CHARGE_AMT":"4359.24","PSPS_ASSIGNED_SERVICES_CNT":"453","PSPS_NCH_PAYMENT_AMT":"10308.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"49082","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"81","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"113.93","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"99201","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"24","PSPS_SUBMITTED_CHARGE_AMT":"3000","PSPS_ALLOWED_CHARGE_AMT":"873","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"24","PSPS_NCH_PAYMENT_AMT":"486.36","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"G2010","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"87","PSPS_SUBMITTED_CHARGE_AMT":"2026.04","PSPS_ALLOWED_CHARGE_AMT":"773.21","PSPS_DENIED_SERVICES_CNT":"17","PSPS_DENIED_CHARGE_AMT":"320.01","PSPS_ASSIGNED_SERVICES_CNT":"87","PSPS_NCH_PAYMENT_AMT":"532.47","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"99441","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"65","PSPS_SUBMITTED_CHARGE_AMT":"4321.3","PSPS_ALLOWED_CHARGE_AMT":"1538.55","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"65","PSPS_NCH_PAYMENT_AMT":"1246.93","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"43239","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"93","PSPS_SUBMITTED_CHARGE_AMT":"44227","PSPS_ALLOWED_CHARGE_AMT":"12305","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"93","PSPS_NCH_PAYMENT_AMT":"8940.67","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"99454","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"62","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"236.65","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1A"},{"HCPCS_CD":"00812","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"P3","PSPS_SUBMITTED_SERVICE_CNT":"395","PSPS_SUBMITTED_CHARGE_AMT":"276163","PSPS_ALLOWED_CHARGE_AMT":"39407.58","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"395","PSPS_NCH_PAYMENT_AMT":"37728.98","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"93282","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2C"},{"HCPCS_CD":"93228","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"B6","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"84.02","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2C"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"35.83","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"G8510","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"12042","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"22","PSPS_SUBMITTED_CHARGE_AMT":"6864","PSPS_ALLOWED_CHARGE_AMT":"2159.3","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"22","PSPS_NCH_PAYMENT_AMT":"1756.48","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"93010","HCPCS_INITIAL_MODIFIER_CD":"77","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"664","PSPS_SUBMITTED_CHARGE_AMT":"19614","PSPS_ALLOWED_CHARGE_AMT":"5744.12","PSPS_DENIED_SERVICES_CNT":"28","PSPS_DENIED_CHARGE_AMT":"788","PSPS_ASSIGNED_SERVICES_CNT":"664","PSPS_NCH_PAYMENT_AMT":"4447.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2A"},{"HCPCS_CD":"43249","HCPCS_INITIAL_MODIFIER_CD":"XS","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"562.07","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"UNK","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":""},{"HCPCS_CD":"64490","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"123.62","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"64494","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GZ","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"11422","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"03602","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"139.28","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"97014","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GP","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"56515","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"98","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"170.63","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"13102","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"60.36","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"V5240","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"64","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"K","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1F"},{"HCPCS_CD":"96372","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"37","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"12.72","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"38724","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":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1146.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"99202","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"D7","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"59.58","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"GV","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"1228.81","PSPS_ALLOWED_CHARGE_AMT":"736.32","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"590.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"XU","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"48.71","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"20611","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"237.39","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4C"},{"HCPCS_CD":"11200","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"2227","PSPS_ALLOWED_CHARGE_AMT":"83.05","PSPS_DENIED_SERVICES_CNT":"12","PSPS_DENIED_CHARGE_AMT":"2089","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"66.21","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"95","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"69.39","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"38900","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"237.78","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"73223","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":"76","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"80.3","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"20611","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"167.69","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4C"},{"HCPCS_CD":"70544","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"46.79","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"I2C"},{"HCPCS_CD":"70552","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":"MH","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"446.87","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2C"},{"HCPCS_CD":"90834","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"68","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"99","PSPS_SUBMITTED_CHARGE_AMT":"19834","PSPS_ALLOWED_CHARGE_AMT":"8128.28","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"99","PSPS_NCH_PAYMENT_AMT":"6363.58","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"64772","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"32.36","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"GE","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"11308","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"236.32","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"G0439","HCPCS_INITIAL_MODIFIER_CD":"FP","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"112.36","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"99222","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"502.64","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"71046","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"03602","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"149","PSPS_SUBMITTED_CHARGE_AMT":"20959.92","PSPS_ALLOWED_CHARGE_AMT":"3798.9","PSPS_DENIED_SERVICES_CNT":"14","PSPS_DENIED_CHARGE_AMT":"1876.6","PSPS_ASSIGNED_SERVICES_CNT":"149","PSPS_NCH_PAYMENT_AMT":"2491.87","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1A"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"527.27","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"45380","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"292.53","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"72100","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"C6","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"9.74","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"31","PSPS_SUBMITTED_CHARGE_AMT":"2944","PSPS_ALLOWED_CHARGE_AMT":"2169.78","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"31","PSPS_NCH_PAYMENT_AMT":"1392.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"00600","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"P2","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"520.97","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"00670","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"P3","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"525.77","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"87880","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"99.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"27810","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"99497","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"68.76","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"11623","HCPCS_INITIAL_MODIFIER_CD":"51","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":"","PSPS_SUBMITTED_SERVICE_CNT":"439","PSPS_SUBMITTED_CHARGE_AMT":"248540.72","PSPS_ALLOWED_CHARGE_AMT":"63928.32","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"439","PSPS_NCH_PAYMENT_AMT":"49457","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"13160","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"655.69","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"73221","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"63","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"MH","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"G0105","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"802.74","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"93505","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"360.54","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"47490","HCPCS_INITIAL_MODIFIER_CD":"51","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"36.55","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"44120","HCPCS_INITIAL_MODIFIER_CD":"82","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"164.45","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"73630","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"B9","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"25.79","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"94660","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"31.03","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2C"},{"HCPCS_CD":"97168","HCPCS_INITIAL_MODIFIER_CD":"GO","PROVIDER_SPEC_CD":"67","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"39","PSPS_SUBMITTED_CHARGE_AMT":"4350","PSPS_ALLOWED_CHARGE_AMT":"2169.36","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"39","PSPS_NCH_PAYMENT_AMT":"1594.36","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"33270","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"657.76","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"34713","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"62","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"138.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"73206","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"75.5","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"27360","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"734.46","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"G9708","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"64491","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"566.53","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"73030","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"26123","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"15","PSPS_SUBMITTED_CHARGE_AMT":"51607","PSPS_ALLOWED_CHARGE_AMT":"12856.95","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"15","PSPS_NCH_PAYMENT_AMT":"10187.2","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"43281","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"313.32","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8I"},{"HCPCS_CD":"69100","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"124","PSPS_SUBMITTED_CHARGE_AMT":"28934.76","PSPS_ALLOWED_CHARGE_AMT":"9356.56","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"124","PSPS_NCH_PAYMENT_AMT":"6409.79","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"72070","HCPCS_INITIAL_MODIFIER_CD":"FY","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"78.08","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"66984","HCPCS_INITIAL_MODIFIER_CD":"55","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"50","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4B"},{"HCPCS_CD":"36223","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"162326","PSPS_ALLOWED_CHARGE_AMT":"3178.05","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"2537.79","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"29125","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"29.59","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"U0001","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"L2210","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"53","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"10","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"284.43","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"28825","HCPCS_INITIAL_MODIFIER_CD":"XS","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"T1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"158.06","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"71045","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":"23","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"3111","PSPS_SUBMITTED_CHARGE_AMT":"104792.33","PSPS_ALLOWED_CHARGE_AMT":"27511.4","PSPS_DENIED_SERVICES_CNT":"101","PSPS_DENIED_CHARGE_AMT":"3325","PSPS_ASSIGNED_SERVICES_CNT":"3111","PSPS_NCH_PAYMENT_AMT":"20970.51","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1A"},{"HCPCS_CD":"28270","HCPCS_INITIAL_MODIFIER_CD":"RT","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","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"399.63","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"27427","HCPCS_INITIAL_MODIFIER_CD":"XU","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":"78","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"380.37","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"20552","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"92250","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"327","PSPS_SUBMITTED_CHARGE_AMT":"24328.46","PSPS_ALLOWED_CHARGE_AMT":"13448.5","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"327","PSPS_NCH_PAYMENT_AMT":"9017.77","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5C"},{"HCPCS_CD":"61584","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2045.66","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"99223","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"AI","PSPS_SUBMITTED_SERVICE_CNT":"76","PSPS_SUBMITTED_CHARGE_AMT":"31456","PSPS_ALLOWED_CHARGE_AMT":"14059.44","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"76","PSPS_NCH_PAYMENT_AMT":"11147.29","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"88333","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"34","PSPS_SUBMITTED_CHARGE_AMT":"8005","PSPS_ALLOWED_CHARGE_AMT":"2140.71","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"34","PSPS_NCH_PAYMENT_AMT":"1717.62","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1G"},{"HCPCS_CD":"71101","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"37232","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"326.63","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"3345F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"85048","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"145","PSPS_SUBMITTED_CHARGE_AMT":"1540.7","PSPS_ALLOWED_CHARGE_AMT":"342.9","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"145","PSPS_NCH_PAYMENT_AMT":"335.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1D"},{"HCPCS_CD":"A0433","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"QL","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"933.88","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1A"},{"HCPCS_CD":"57288","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"300.2","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"J7608","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"64","PSPS_SUBMITTED_CHARGE_AMT":"249","PSPS_ALLOWED_CHARGE_AMT":"180.75","PSPS_DENIED_SERVICES_CNT":"11","PSPS_DENIED_CHARGE_AMT":"34","PSPS_ASSIGNED_SERVICES_CNT":"64","PSPS_NCH_PAYMENT_AMT":"130.91","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1G"},{"HCPCS_CD":"43239","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"575.7","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"57.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"44141","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"78","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"257.69","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1B"},{"HCPCS_CD":"22558","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"696.2","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"155.6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2C"},{"HCPCS_CD":"95822","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"C0","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"93312","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"53","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"57.99","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3C"},{"HCPCS_CD":"93303","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"37","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3C"},{"HCPCS_CD":"93321","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"03602","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"41","PSPS_SUBMITTED_CHARGE_AMT":"6853.83","PSPS_ALLOWED_CHARGE_AMT":"293.67","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"41","PSPS_NCH_PAYMENT_AMT":"236.78","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3C"},{"HCPCS_CD":"93289","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"30.1","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"L1810","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"3125","PSPS_ALLOWED_CHARGE_AMT":"1006.3","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"801.78","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"70543","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"86.24","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2C"},{"HCPCS_CD":"49565","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"785.82","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"11043","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"253.22","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"G0416","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"30","PSPS_SUBMITTED_CHARGE_AMT":"6750","PSPS_ALLOWED_CHARGE_AMT":"5544.3","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"30","PSPS_NCH_PAYMENT_AMT":"4371.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1G"},{"HCPCS_CD":"36573","HCPCS_INITIAL_MODIFIER_CD":"52","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"75.12","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"73630","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"17.37","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"2408","PSPS_ALLOWED_CHARGE_AMT":"644.84","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"382.53","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"90662","HCPCS_INITIAL_MODIFIER_CD":"X1","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"117","PSPS_SUBMITTED_CHARGE_AMT":"6903","PSPS_ALLOWED_CHARGE_AMT":"6298.05","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"117","PSPS_NCH_PAYMENT_AMT":"6292.45","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1G"},{"HCPCS_CD":"99305","HCPCS_INITIAL_MODIFIER_CD":"GT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"65","PSPS_SUBMITTED_CHARGE_AMT":"21389.06","PSPS_ALLOWED_CHARGE_AMT":"7943.6","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"65","PSPS_NCH_PAYMENT_AMT":"6318.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"74022","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"26746","HCPCS_INITIAL_MODIFIER_CD":"FA","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"552.96","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"E2510","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"46","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1E"},{"HCPCS_CD":"1124F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"52","PSPS_SUBMITTED_CHARGE_AMT":"0.52","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"52","PSPS_DENIED_CHARGE_AMT":"0.52","PSPS_ASSIGNED_SERVICES_CNT":"52","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"36620","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"75.68","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"11055","HCPCS_INITIAL_MODIFIER_CD":"Q8","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"4592","PSPS_SUBMITTED_CHARGE_AMT":"397383.18","PSPS_ALLOWED_CHARGE_AMT":"307607.8","PSPS_DENIED_SERVICES_CNT":"294","PSPS_DENIED_CHARGE_AMT":"26973.77","PSPS_ASSIGNED_SERVICES_CNT":"4592","PSPS_NCH_PAYMENT_AMT":"220240.36","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"88332","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"3","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"26.26","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1G"},{"HCPCS_CD":"01922","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"X4","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"81.72","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"01840","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"172.39","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"34111","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"425.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"15100","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"262.63","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"64617","HCPCS_INITIAL_MODIFIER_CD":"50","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":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"236.59","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"A6407","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"17013","PRICING_LOCALITY_CD":"24","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"117","PSPS_SUBMITTED_CHARGE_AMT":"238.03","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"117","PSPS_DENIED_CHARGE_AMT":"238.03","PSPS_ASSIGNED_SERVICES_CNT":"117","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1A"},{"HCPCS_CD":"21935","HCPCS_INITIAL_MODIFIER_CD":"","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"869.81","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"11310","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"37.26","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"G8752","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1567","PSPS_SUBMITTED_CHARGE_AMT":"19.34","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"1567","PSPS_DENIED_CHARGE_AMT":"19.34","PSPS_ASSIGNED_SERVICES_CNT":"1567","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"23","PSPS_SUBMITTED_CHARGE_AMT":"6302","PSPS_ALLOWED_CHARGE_AMT":"2450.88","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"23","PSPS_NCH_PAYMENT_AMT":"1971.89","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"97014","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"12102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"19","PSPS_SUBMITTED_CHARGE_AMT":"911","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"19","PSPS_DENIED_CHARGE_AMT":"911","PSPS_ASSIGNED_SERVICES_CNT":"19","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"J3245","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"201","PSPS_SUBMITTED_CHARGE_AMT":"57864","PSPS_ALLOWED_CHARGE_AMT":"27273.1","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"201","PSPS_NCH_PAYMENT_AMT":"21818.48","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"G9903","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"44","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"24","PSPS_SUBMITTED_CHARGE_AMT":"0.1","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"24","PSPS_DENIED_CHARGE_AMT":"0.1","PSPS_ASSIGNED_SERVICES_CNT":"24","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"76000","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":"CR","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"17.37","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"93880","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"Q1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"28.42","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3D"},{"HCPCS_CD":"47120","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"91","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"4224.29","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"83921","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"09202","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"84","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"51798","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"48.88","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"71046","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"B2","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"AQ","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1A"},{"HCPCS_CD":"94640","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"78070","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"36","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"301.2","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1E"},{"HCPCS_CD":"73650","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"11105","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"47.63","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"70486","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":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"65.16","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2A"},{"HCPCS_CD":"29827","HCPCS_INITIAL_MODIFIER_CD":"AG","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8A"},{"HCPCS_CD":"37211","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"X4","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"327.49","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"21030","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"85","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"12032","PSPS_ALLOWED_CHARGE_AMT":"6107.81","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"4824.8","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"87426","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"123","PSPS_SUBMITTED_CHARGE_AMT":"26525","PSPS_ALLOWED_CHARGE_AMT":"4613.46","PSPS_DENIED_SERVICES_CNT":"21","PSPS_DENIED_CHARGE_AMT":"5050","PSPS_ASSIGNED_SERVICES_CNT":"123","PSPS_NCH_PAYMENT_AMT":"4613.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"27758","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"393.16","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C6","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"72","PSPS_SUBMITTED_CHARGE_AMT":"20479.63","PSPS_ALLOWED_CHARGE_AMT":"7085.6","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"72","PSPS_NCH_PAYMENT_AMT":"5545.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"67108","HCPCS_INITIAL_MODIFIER_CD":"RT","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":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1452.47","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4C"},{"HCPCS_CD":"36620","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"74183","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"46","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"247.01","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"97535","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"147.42","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"11640","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"47.92","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"A4426","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"30","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"80","PSPS_SUBMITTED_CHARGE_AMT":"519.32","PSPS_ALLOWED_CHARGE_AMT":"253.6","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"80","PSPS_NCH_PAYMENT_AMT":"201.87","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"G8420","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"72190","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":"23","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"10.24","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"20553","HCPCS_INITIAL_MODIFIER_CD":"XS","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"80","PSPS_SUBMITTED_CHARGE_AMT":"22378","PSPS_ALLOWED_CHARGE_AMT":"4457.7","PSPS_DENIED_SERVICES_CNT":"15","PSPS_DENIED_CHARGE_AMT":"4200","PSPS_ASSIGNED_SERVICES_CNT":"80","PSPS_NCH_PAYMENT_AMT":"3606.07","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"75710","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"2572.22","PSPS_ALLOWED_CHARGE_AMT":"852.3","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"687.42","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"74018","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"A9","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"15.44","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"43239","HCPCS_INITIAL_MODIFIER_CD":"SG","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"45","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"XS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"154.64","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"94660","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"53.86","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2C"},{"HCPCS_CD":"99285","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"CS","PSPS_SUBMITTED_SERVICE_CNT":"744","PSPS_SUBMITTED_CHARGE_AMT":"939117.06","PSPS_ALLOWED_CHARGE_AMT":"97987.11","PSPS_DENIED_SERVICES_CNT":"109","PSPS_DENIED_CHARGE_AMT":"119172","PSPS_ASSIGNED_SERVICES_CNT":"744","PSPS_NCH_PAYMENT_AMT":"98148.87","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M3"},{"HCPCS_CD":"87428","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"63.59","PSPS_HCPCS_ASC_IND_CD":"","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":""},{"HCPCS_CD":"3060F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"261","PSPS_SUBMITTED_CHARGE_AMT":"5.4","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"261","PSPS_DENIED_CHARGE_AMT":"5.4","PSPS_ASSIGNED_SERVICES_CNT":"261","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"58","PSPS_SUBMITTED_SERVICE_CNT":"30","PSPS_SUBMITTED_CHARGE_AMT":"7138","PSPS_ALLOWED_CHARGE_AMT":"1811.7","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"30","PSPS_NCH_PAYMENT_AMT":"1401.76","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"547.01","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"93284","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"50","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"82668","HCPCS_INITIAL_MODIFIER_CD":"90","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"18.79","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"99442","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"105","PSPS_SUBMITTED_CHARGE_AMT":"9628","PSPS_ALLOWED_CHARGE_AMT":"5406.96","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"105","PSPS_NCH_PAYMENT_AMT":"4150.43","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"3046F","HCPCS_INITIAL_MODIFIER_CD":"8P","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"28010","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"T3","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"11424","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":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"93306","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"61.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3C"},{"HCPCS_CD":"10061","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"184.34","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"L5620","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"53","CARRIER_NUM":"17013","PRICING_LOCALITY_CD":"36","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"K2","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"704.63","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"69100","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"76","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"396.18","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"36015","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"99024","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"72170","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"76","PSPS_SUBMITTED_SERVICE_CNT":"20","PSPS_SUBMITTED_CHARGE_AMT":"1495","PSPS_ALLOWED_CHARGE_AMT":"114.09","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"20","PSPS_NCH_PAYMENT_AMT":"92.22","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"G0179","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C6","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"93","PSPS_SUBMITTED_CHARGE_AMT":"7498.94","PSPS_ALLOWED_CHARGE_AMT":"3268.19","PSPS_DENIED_SERVICES_CNT":"11","PSPS_DENIED_CHARGE_AMT":"860.98","PSPS_ASSIGNED_SERVICES_CNT":"93","PSPS_NCH_PAYMENT_AMT":"2455.86","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"Q5","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"169.23","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"97530","HCPCS_INITIAL_MODIFIER_CD":"GO","PROVIDER_SPEC_CD":"67","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"42","PSPS_SUBMITTED_CHARGE_AMT":"2608.2","PSPS_ALLOWED_CHARGE_AMT":"1483.26","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"42","PSPS_NCH_PAYMENT_AMT":"1178.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"33967","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"195.57","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"61322","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"AS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"276.03","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"93979","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"138.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3F"},{"HCPCS_CD":"11044","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"378.16","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"180.85","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2C"},{"HCPCS_CD":"70450","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"MH","PSPS_SUBMITTED_SERVICE_CNT":"20","PSPS_SUBMITTED_CHARGE_AMT":"3074","PSPS_ALLOWED_CHARGE_AMT":"834.02","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"20","PSPS_NCH_PAYMENT_AMT":"642.06","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2A"},{"HCPCS_CD":"64492","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"28","PSPS_SUBMITTED_CHARGE_AMT":"20606.58","PSPS_ALLOWED_CHARGE_AMT":"199.8","PSPS_DENIED_SERVICES_CNT":"25","PSPS_DENIED_CHARGE_AMT":"17735.58","PSPS_ASSIGNED_SERVICES_CNT":"28","PSPS_NCH_PAYMENT_AMT":"160.02","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"99307","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"38","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"158","PSPS_SUBMITTED_CHARGE_AMT":"13704","PSPS_ALLOWED_CHARGE_AMT":"6745.6","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"158","PSPS_NCH_PAYMENT_AMT":"4654.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"88112","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"22","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"D1","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"22.81","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1G"},{"HCPCS_CD":"76377","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"226.49","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"22612","HCPCS_INITIAL_MODIFIER_CD":"79","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1387.9","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"73000","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"205.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"90792","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"26","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"71","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"100","PSPS_SUBMITTED_CHARGE_AMT":"43762","PSPS_ALLOWED_CHARGE_AMT":"12277.36","PSPS_DENIED_SERVICES_CNT":"17","PSPS_DENIED_CHARGE_AMT":"7482","PSPS_ASSIGNED_SERVICES_CNT":"100","PSPS_NCH_PAYMENT_AMT":"8397.39","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"25210","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"54.45","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"L3260","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"49","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"G0442","HCPCS_INITIAL_MODIFIER_CD":"XS","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"60","PSPS_SUBMITTED_CHARGE_AMT":"2402","PSPS_ALLOWED_CHARGE_AMT":"1026.61","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"60","PSPS_NCH_PAYMENT_AMT":"1037.08","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"73720","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"5679","PSPS_ALLOWED_CHARGE_AMT":"1319.76","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"1066.06","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"72040","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":"21","HCPCS_SECOND_MODIFIER_CD":"52","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"26.73","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"96138","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"36.2","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"96372","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"72","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"12.61","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99211","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"89.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"99291","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"9324","PSPS_SUBMITTED_CHARGE_AMT":"7618011.92","PSPS_ALLOWED_CHARGE_AMT":"1716812.2","PSPS_DENIED_SERVICES_CNT":"399","PSPS_DENIED_CHARGE_AMT":"320243","PSPS_ASSIGNED_SERVICES_CNT":"9324","PSPS_NCH_PAYMENT_AMT":"1368666.51","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2C"},{"HCPCS_CD":"26370","HCPCS_INITIAL_MODIFIER_CD":"F2","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"509.19","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"20526","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"66.77","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"36247","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"15","PSPS_SUBMITTED_CHARGE_AMT":"5038.02","PSPS_ALLOWED_CHARGE_AMT":"2196.45","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"15","PSPS_NCH_PAYMENT_AMT":"1772.33","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"76519","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"24.79","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3A"},{"HCPCS_CD":"11046","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"341.99","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"99211","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"46","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"25","PSPS_SUBMITTED_CHARGE_AMT":"1303.07","PSPS_ALLOWED_CHARGE_AMT":"510.74","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"25","PSPS_NCH_PAYMENT_AMT":"393.93","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"71045","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"71","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"147","PSPS_SUBMITTED_CHARGE_AMT":"8265","PSPS_ALLOWED_CHARGE_AMT":"1105.68","PSPS_DENIED_SERVICES_CNT":"11","PSPS_DENIED_CHARGE_AMT":"616","PSPS_ASSIGNED_SERVICES_CNT":"147","PSPS_NCH_PAYMENT_AMT":"834.22","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1A"},{"HCPCS_CD":"64420","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"48.9","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"29823","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"79","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"66.54","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8A"},{"HCPCS_CD":"11901","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"71","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"AQ","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"1586","PSPS_ALLOWED_CHARGE_AMT":"878.88","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"610.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"11402","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"395.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"31502","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"28.14","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"20605","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"234.27","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"43239","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"76499","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"76","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"44.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"J7321","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"132.22","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"73552","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"19.53","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"64405","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"0295T","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"26","PSPS_SUBMITTED_CHARGE_AMT":"28838","PSPS_ALLOWED_CHARGE_AMT":"8809.25","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"26","PSPS_NCH_PAYMENT_AMT":"7023.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2C"},{"HCPCS_CD":"20930","HCPCS_INITIAL_MODIFIER_CD":"79","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":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"26860","HCPCS_INITIAL_MODIFIER_CD":"F9","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"5701.35","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"01936","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"P1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"226.22","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"94640","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"09302","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"69","PSPS_SUBMITTED_CHARGE_AMT":"1330.82","PSPS_ALLOWED_CHARGE_AMT":"1053.47","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"69","PSPS_NCH_PAYMENT_AMT":"665.83","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"72072","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"73","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"X5","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"29.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"35001","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"130.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"72141","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"B6","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"266.3","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"G0103","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1792","PSPS_SUBMITTED_CHARGE_AMT":"120264.85","PSPS_ALLOWED_CHARGE_AMT":"26705.73","PSPS_DENIED_SERVICES_CNT":"409","PSPS_DENIED_CHARGE_AMT":"27865.59","PSPS_ASSIGNED_SERVICES_CNT":"1792","PSPS_NCH_PAYMENT_AMT":"26319.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"20610","HCPCS_INITIAL_MODIFIER_CD":"XS","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"54.04","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"37236","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"194.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2B"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"GQ","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"33.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"99347","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"45.35","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4A"},{"HCPCS_CD":"33430","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"186.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"66682","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2235.98","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"00840","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"XE","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"684.8","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"L5988","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"57","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"53","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1621.74","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"99309","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"2806","PSPS_SUBMITTED_CHARGE_AMT":"585793.7","PSPS_ALLOWED_CHARGE_AMT":"222674.06","PSPS_DENIED_SERVICES_CNT":"62","PSPS_DENIED_CHARGE_AMT":"12868.98","PSPS_ASSIGNED_SERVICES_CNT":"2806","PSPS_NCH_PAYMENT_AMT":"164191.91","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"20902","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"49.5","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"80430","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"67880","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"153.05","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"A4259","HCPCS_INITIAL_MODIFIER_CD":"KL","PROVIDER_SPEC_CD":"A6","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"11.93","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"D1E"},{"HCPCS_CD":"73140","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"116.92","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"11601","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"442.87","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"11107","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"60.01","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99387","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"A7033","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"A6","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"46","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1E"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"51","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"85.02","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"52332","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"17","PSPS_SUBMITTED_CHARGE_AMT":"17931.48","PSPS_ALLOWED_CHARGE_AMT":"2703.73","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"17","PSPS_NCH_PAYMENT_AMT":"2005.75","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8E"},{"HCPCS_CD":"4040F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"99307","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"38","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"23","PSPS_SUBMITTED_CHARGE_AMT":"1206.24","PSPS_ALLOWED_CHARGE_AMT":"1011.24","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"23","PSPS_NCH_PAYMENT_AMT":"804.99","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"27446","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3C"},{"HCPCS_CD":"99233","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"579","PSPS_SUBMITTED_CHARGE_AMT":"156443","PSPS_ALLOWED_CHARGE_AMT":"58228.34","PSPS_DENIED_SERVICES_CNT":"50","PSPS_DENIED_CHARGE_AMT":"13602","PSPS_ASSIGNED_SERVICES_CNT":"579","PSPS_NCH_PAYMENT_AMT":"45920.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"99231","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C7","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"161.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"99292","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"89.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2C"},{"HCPCS_CD":"99219","HCPCS_INITIAL_MODIFIER_CD":"CS","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"AI","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"135.84","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"73000","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"17","PSPS_SUBMITTED_CHARGE_AMT":"653.65","PSPS_ALLOWED_CHARGE_AMT":"653.65","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"17","PSPS_NCH_PAYMENT_AMT":"491.26","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"93931","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"60.05","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3F"},{"HCPCS_CD":"82533","HCPCS_INITIAL_MODIFIER_CD":"91","PROVIDER_SPEC_CD":"46","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"31.94","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"64643","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"76.05","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"28232","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"T1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"151.49","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"4010F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"765","PSPS_SUBMITTED_CHARGE_AMT":"0.05","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"765","PSPS_DENIED_CHARGE_AMT":"0.05","PSPS_ASSIGNED_SERVICES_CNT":"765","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"99292","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"70","PSPS_SUBMITTED_CHARGE_AMT":"44165","PSPS_ALLOWED_CHARGE_AMT":"7573.86","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"70","PSPS_NCH_PAYMENT_AMT":"6064.74","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2C"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"129.73","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"99495","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"126.62","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"V2300","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"96","CARRIER_NUM":"17013","PRICING_LOCALITY_CD":"24","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"112","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"01464","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"475.14","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"99211","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"25","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"91.61","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"64708","HCPCS_INITIAL_MODIFIER_CD":"LT","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":"XS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"928.86","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"76705","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"Q6","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"141.78","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3B"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"288.24","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"G6013","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"E7","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"16","PSPS_SUBMITTED_CHARGE_AMT":"8290.43","PSPS_ALLOWED_CHARGE_AMT":"3816.32","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"16","PSPS_NCH_PAYMENT_AMT":"3053.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P7A"},{"HCPCS_CD":"27096","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"67.27","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"28750","HCPCS_INITIAL_MODIFIER_CD":"TA","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"522.99","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"3285F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"70","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"88341","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"975","PSPS_SUBMITTED_CHARGE_AMT":"111385.25","PSPS_ALLOWED_CHARGE_AMT":"58055.1","PSPS_DENIED_SERVICES_CNT":"105","PSPS_DENIED_CHARGE_AMT":"11866.56","PSPS_ASSIGNED_SERVICES_CNT":"975","PSPS_NCH_PAYMENT_AMT":"45937.28","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"L1851","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"9","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"99222","HCPCS_INITIAL_MODIFIER_CD":"AI","PROVIDER_SPEC_CD":"C6","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"190","PSPS_SUBMITTED_CHARGE_AMT":"48260","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"190","PSPS_DENIED_CHARGE_AMT":"48260","PSPS_ASSIGNED_SERVICES_CNT":"190","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"43248","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"15","PSPS_SUBMITTED_CHARGE_AMT":"15708","PSPS_ALLOWED_CHARGE_AMT":"2486.85","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"15","PSPS_NCH_PAYMENT_AMT":"1867.08","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"33241","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GZ","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2E"},{"HCPCS_CD":"72132","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"QQ","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"48.79","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"64450","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":"T1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"21.45","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"CS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"66.67","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"50688","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"61.29","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"11420","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"53.64","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"11755","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":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"2555.01","PSPS_ALLOWED_CHARGE_AMT":"1460.76","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"1098.67","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"29075","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"48.19","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"L3808","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"45","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"71260","HCPCS_INITIAL_MODIFIER_CD":"XP","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"D7","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"172.84","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"A6252","HCPCS_INITIAL_MODIFIER_CD":"A1","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"60","PSPS_SUBMITTED_CHARGE_AMT":"327.6","PSPS_ALLOWED_CHARGE_AMT":"226.8","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"60","PSPS_NCH_PAYMENT_AMT":"177.81","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"D1A"},{"HCPCS_CD":"J0897","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1080","PSPS_SUBMITTED_CHARGE_AMT":"32400","PSPS_ALLOWED_CHARGE_AMT":"21493.08","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"1080","PSPS_NCH_PAYMENT_AMT":"17194.5","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"A0429","HCPCS_INITIAL_MODIFIER_CD":"SH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"GY","PSPS_SUBMITTED_SERVICE_CNT":"579","PSPS_SUBMITTED_CHARGE_AMT":"294077.05","PSPS_ALLOWED_CHARGE_AMT":"2028.22","PSPS_DENIED_SERVICES_CNT":"573","PSPS_DENIED_CHARGE_AMT":"291218.95","PSPS_ASSIGNED_SERVICES_CNT":"579","PSPS_NCH_PAYMENT_AMT":"1590.14","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1A"},{"HCPCS_CD":"17271","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"3570.17","PSPS_ALLOWED_CHARGE_AMT":"741.84","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"555.6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"71120","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"6.96","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"31624","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2.84","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8F"},{"HCPCS_CD":"V5014","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"K","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1F"},{"HCPCS_CD":"11045","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"10120","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"57.49","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"75630","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"77334","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"26","PSPS_SUBMITTED_CHARGE_AMT":"2336.66","PSPS_ALLOWED_CHARGE_AMT":"1623.96","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"26","PSPS_NCH_PAYMENT_AMT":"1316.74","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P7A"},{"HCPCS_CD":"99334","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"50.94","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"33016","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"417.46","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"90674","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"14","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"70","PSPS_SUBMITTED_CHARGE_AMT":"2940","PSPS_ALLOWED_CHARGE_AMT":"1985.44","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"70","PSPS_NCH_PAYMENT_AMT":"1984.32","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1G"},{"HCPCS_CD":"99222","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"81","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"111.98","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"93880","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"67","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"33.76","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3D"},{"HCPCS_CD":"27236","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"44975","PSPS_ALLOWED_CHARGE_AMT":"13526.92","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"10807.37","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3A"},{"HCPCS_CD":"01464","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"81.55","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"73700","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"158.87","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"87150","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"140.36","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"20611","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"50","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"108.6","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4C"},{"HCPCS_CD":"44369","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"102.83","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8I"},{"HCPCS_CD":"42426","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2159.8","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"73030","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"169.07","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"99441","HCPCS_INITIAL_MODIFIER_CD":"CC","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"36415","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"20.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1A"},{"HCPCS_CD":"37233","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"265.07","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"92523","HCPCS_INITIAL_MODIFIER_CD":"GN","PROVIDER_SPEC_CD":"15","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"80","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"61781","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"27486","HCPCS_INITIAL_MODIFIER_CD":"RT","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":"GC","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"57678","PSPS_ALLOWED_CHARGE_AMT":"18552.43","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"14868.8","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"28315","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"252.68","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"90961","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"199","PSPS_SUBMITTED_CHARGE_AMT":"400491","PSPS_ALLOWED_CHARGE_AMT":"53175.8","PSPS_DENIED_SERVICES_CNT":"11","PSPS_DENIED_CHARGE_AMT":"24839","PSPS_ASSIGNED_SERVICES_CNT":"199","PSPS_NCH_PAYMENT_AMT":"41669.95","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P9A"},{"HCPCS_CD":"73560","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"53.55","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"75820","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":"","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"4413","PSPS_ALLOWED_CHARGE_AMT":"468.86","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"376.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"A0427","HCPCS_INITIAL_MODIFIER_CD":"HH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"76","PSPS_SUBMITTED_SERVICE_CNT":"23","PSPS_SUBMITTED_CHARGE_AMT":"32386.34","PSPS_ALLOWED_CHARGE_AMT":"11806.49","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"23","PSPS_NCH_PAYMENT_AMT":"9375.87","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1A"},{"HCPCS_CD":"85651","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"4.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"10060","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"46","PSPS_SUBMITTED_CHARGE_AMT":"10826","PSPS_ALLOWED_CHARGE_AMT":"4761.01","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"46","PSPS_NCH_PAYMENT_AMT":"3486.61","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"45388","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"727.35","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"93000","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"53","PSPS_SUBMITTED_CHARGE_AMT":"3359.5","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"53","PSPS_DENIED_CHARGE_AMT":"3359.5","PSPS_ASSIGNED_SERVICES_CNT":"53","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2A"},{"HCPCS_CD":"64415","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"100.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"76377","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"X5","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"63.99","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"20552","HCPCS_INITIAL_MODIFIER_CD":"59","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":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"43.04","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"43276","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1215.53","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"64425","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"45.01","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"37242","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"405.56","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"26615","HCPCS_INITIAL_MODIFIER_CD":"F8","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1951.61","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"26210","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":"F9","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"L0472","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"17013","PRICING_LOCALITY_CD":"24","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"324.11","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"L4350","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"50382","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"179.28","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"90715","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1324","PSPS_SUBMITTED_CHARGE_AMT":"105286.7","PSPS_ALLOWED_CHARGE_AMT":"6785.4","PSPS_DENIED_SERVICES_CNT":"1122","PSPS_DENIED_CHARGE_AMT":"88001.96","PSPS_ASSIGNED_SERVICES_CNT":"1324","PSPS_NCH_PAYMENT_AMT":"4813.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"15771","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"192.78","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"64493","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"67.94","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"36907","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"118.71","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"26160","HCPCS_INITIAL_MODIFIER_CD":"XS","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"F1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"471.08","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"Q1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"18.86","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"99310","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"38","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"55","PSPS_SUBMITTED_CHARGE_AMT":"17401","PSPS_ALLOWED_CHARGE_AMT":"7601.55","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"55","PSPS_NCH_PAYMENT_AMT":"5397.83","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"99315","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"113.94","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"77063","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"52","PSPS_SUBMITTED_SERVICE_CNT":"625","PSPS_SUBMITTED_CHARGE_AMT":"79397","PSPS_ALLOWED_CHARGE_AMT":"8623.23","PSPS_DENIED_SERVICES_CNT":"32","PSPS_DENIED_CHARGE_AMT":"3644","PSPS_ASSIGNED_SERVICES_CNT":"625","PSPS_NCH_PAYMENT_AMT":"8482.06","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1C"},{"HCPCS_CD":"97110","HCPCS_INITIAL_MODIFIER_CD":"GO","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"599.97","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"GE","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"63","PSPS_SUBMITTED_CHARGE_AMT":"8735","PSPS_ALLOWED_CHARGE_AMT":"3403.8","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"63","PSPS_NCH_PAYMENT_AMT":"2276.25","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"73630","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"5.88","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"85999","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"78","PSPS_SUBMITTED_CHARGE_AMT":"5182.86","PSPS_ALLOWED_CHARGE_AMT":"296.52","PSPS_DENIED_SERVICES_CNT":"36","PSPS_DENIED_CHARGE_AMT":"2388.96","PSPS_ASSIGNED_SERVICES_CNT":"78","PSPS_NCH_PAYMENT_AMT":"231.24","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"71275","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"53","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"183","PSPS_SUBMITTED_CHARGE_AMT":"73749","PSPS_ALLOWED_CHARGE_AMT":"18181.45","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"183","PSPS_NCH_PAYMENT_AMT":"14585.66","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"76098","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"XS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"127.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1C"},{"HCPCS_CD":"86580","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"17","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1G"},{"HCPCS_CD":"70547","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":"19","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"272.62","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2C"},{"HCPCS_CD":"74280","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"63","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"268.35","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1D"},{"HCPCS_CD":"28810","HCPCS_INITIAL_MODIFIER_CD":"LT","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":"58","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"339.32","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"37220","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2403.09","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"11720","HCPCS_INITIAL_MODIFIER_CD":"Q7","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"33","PSPS_SUBMITTED_CHARGE_AMT":"1706","PSPS_ALLOWED_CHARGE_AMT":"992.96","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"33","PSPS_NCH_PAYMENT_AMT":"710.67","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"76080","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"XS","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"1023","PSPS_ALLOWED_CHARGE_AMT":"307.23","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"247.81","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"A4256","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"22","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"26","PSPS_SUBMITTED_CHARGE_AMT":"287.48","PSPS_ALLOWED_CHARGE_AMT":"70.98","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"26","PSPS_NCH_PAYMENT_AMT":"51","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1E"},{"HCPCS_CD":"73551","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"69","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"76","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"97760","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"163.48","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"73564","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"633","PSPS_SUBMITTED_CHARGE_AMT":"39055.75","PSPS_ALLOWED_CHARGE_AMT":"7434.4","PSPS_DENIED_SERVICES_CNT":"38","PSPS_DENIED_CHARGE_AMT":"2952.5","PSPS_ASSIGNED_SERVICES_CNT":"633","PSPS_NCH_PAYMENT_AMT":"5288.9","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"52224","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"18","PSPS_SUBMITTED_CHARGE_AMT":"34408","PSPS_ALLOWED_CHARGE_AMT":"2155.58","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"18","PSPS_NCH_PAYMENT_AMT":"1664.56","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8E"},{"HCPCS_CD":"G8420","HCPCS_INITIAL_MODIFIER_CD":"GT","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"63","PSPS_SUBMITTED_CHARGE_AMT":"0","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"63","PSPS_DENIED_CHARGE_AMT":"0","PSPS_ASSIGNED_SERVICES_CNT":"63","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"15769","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"199.22","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"73630","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"800","PSPS_ALLOWED_CHARGE_AMT":"60.34","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"48.09","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"99223","HCPCS_INITIAL_MODIFIER_CD":"AI","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"339.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"20680","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"XU","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"162.82","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"72114","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"193.01","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"29848","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1832.98","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8A"},{"HCPCS_CD":"A0427","HCPCS_INITIAL_MODIFIER_CD":"SH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"GM","PSPS_SUBMITTED_SERVICE_CNT":"28","PSPS_SUBMITTED_CHARGE_AMT":"28300","PSPS_ALLOWED_CHARGE_AMT":"7247.03","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"28","PSPS_NCH_PAYMENT_AMT":"5752.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1A"},{"HCPCS_CD":"13132","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"57","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"96.35","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"11401","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"96.33","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"29240","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"28.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"75809","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"99050","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"06","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"26860","HCPCS_INITIAL_MODIFIER_CD":"F6","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"236.96","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"11442","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"300.61","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"43242","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"44","PSPS_SUBMITTED_CHARGE_AMT":"71257","PSPS_ALLOWED_CHARGE_AMT":"11911.53","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"44","PSPS_NCH_PAYMENT_AMT":"9372.38","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"77771","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"76","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1859.6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"P7A"},{"HCPCS_CD":"49450","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"58.92","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"27823","HCPCS_INITIAL_MODIFIER_CD":"SG","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"3275.4","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"AI","PROVIDER_SPEC_CD":"28","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"57","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"79.58","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"74178","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"80.91","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"15275","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"44","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"44","PSPS_SUBMITTED_CHARGE_AMT":"9050","PSPS_ALLOWED_CHARGE_AMT":"7406.08","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"44","PSPS_NCH_PAYMENT_AMT":"5991.6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"L2385","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"53","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"49","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"401.5","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"62321","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"09","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"165.05","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"01214","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"QS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"548.88","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"96366","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"68.44","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"11102","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"D7","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"32.68","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"87186","HCPCS_INITIAL_MODIFIER_CD":"91","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"8.65","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"99100","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"G8418","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"G9904","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"12","PSPS_SUBMITTED_CHARGE_AMT":"0.12","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"12","PSPS_DENIED_CHARGE_AMT":"0.12","PSPS_ASSIGNED_SERVICES_CNT":"12","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"J7512","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"49","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"12","PSPS_SUBMITTED_CHARGE_AMT":"180","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"12","PSPS_DENIED_CHARGE_AMT":"180","PSPS_ASSIGNED_SERVICES_CNT":"12","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"J0585","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"300","PSPS_SUBMITTED_CHARGE_AMT":"5100","PSPS_ALLOWED_CHARGE_AMT":"1828.2","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"300","PSPS_NCH_PAYMENT_AMT":"1462.56","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"27889","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"495.15","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"35201","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"778.7","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"43281","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1283.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8I"},{"HCPCS_CD":"73030","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"108.59","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"G0108","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"123","PSPS_SUBMITTED_CHARGE_AMT":"15553.36","PSPS_ALLOWED_CHARGE_AMT":"6822.61","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"123","PSPS_NCH_PAYMENT_AMT":"5239.64","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"92523","HCPCS_INITIAL_MODIFIER_CD":"GN","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"154.15","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"92537","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"64","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"650","PSPS_ALLOWED_CHARGE_AMT":"102.74","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"59.58","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"G9599","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"44","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"70551","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"85.19","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"I2C"},{"HCPCS_CD":"21110","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"85","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"93312","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"CR","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"88.65","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3C"},{"HCPCS_CD":"76937","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"75","PSPS_SUBMITTED_CHARGE_AMT":"3777","PSPS_ALLOWED_CHARGE_AMT":"927.3","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"75","PSPS_NCH_PAYMENT_AMT":"747.67","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3F"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"31","PSPS_SUBMITTED_CHARGE_AMT":"7923.48","PSPS_ALLOWED_CHARGE_AMT":"2924.1","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"31","PSPS_NCH_PAYMENT_AMT":"2364.95","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"A6252","HCPCS_INITIAL_MODIFIER_CD":"A1","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"17013","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"510","PSPS_SUBMITTED_CHARGE_AMT":"1927.8","PSPS_ALLOWED_CHARGE_AMT":"1814.4","PSPS_DENIED_SERVICES_CNT":"30","PSPS_DENIED_CHARGE_AMT":"113.4","PSPS_ASSIGNED_SERVICES_CNT":"510","PSPS_NCH_PAYMENT_AMT":"1446.09","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1A"},{"HCPCS_CD":"L1832","HCPCS_INITIAL_MODIFIER_CD":"GZ","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":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"99225","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C6","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"250","PSPS_SUBMITTED_CHARGE_AMT":"46935.44","PSPS_ALLOWED_CHARGE_AMT":"19269.1","PSPS_DENIED_SERVICES_CNT":"17","PSPS_DENIED_CHARGE_AMT":"4149.08","PSPS_ASSIGNED_SERVICES_CNT":"250","PSPS_NCH_PAYMENT_AMT":"15357.14","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"99309","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"28810","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"T1","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"345.88","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"93970","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"26.19","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3F"},{"HCPCS_CD":"64772","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"440.86","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"69990","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"93297","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"32","PSPS_SUBMITTED_CHARGE_AMT":"1715.24","PSPS_ALLOWED_CHARGE_AMT":"545.2","PSPS_DENIED_SERVICES_CNT":"12","PSPS_DENIED_CHARGE_AMT":"635.1","PSPS_ASSIGNED_SERVICES_CNT":"32","PSPS_NCH_PAYMENT_AMT":"413.31","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"29125","HCPCS_INITIAL_MODIFIER_CD":"58","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":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"30.03","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"86146","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"74.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"99231","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"175.97","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"64495","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"13780","PSPS_ALLOWED_CHARGE_AMT":"543.42","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"433.31","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"36558","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"169.07","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"76380","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"16","PSPS_SUBMITTED_CHARGE_AMT":"3184","PSPS_ALLOWED_CHARGE_AMT":"780.3","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"16","PSPS_NCH_PAYMENT_AMT":"589.75","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"97116","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GP","PSPS_SUBMITTED_SERVICE_CNT":"101","PSPS_SUBMITTED_CHARGE_AMT":"5196","PSPS_ALLOWED_CHARGE_AMT":"2165.31","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"101","PSPS_NCH_PAYMENT_AMT":"1726.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"G8431","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"68","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"J2785","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"422.6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"52356","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"50","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"522.16","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"94060","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"F9","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"1950","PSPS_ALLOWED_CHARGE_AMT":"798.07","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"548.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"12001","HCPCS_INITIAL_MODIFIER_CD":"F1","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"90834","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"80","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"75","PSPS_SUBMITTED_CHARGE_AMT":"15075","PSPS_ALLOWED_CHARGE_AMT":"4806.2","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"75","PSPS_NCH_PAYMENT_AMT":"3833","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"26952","HCPCS_INITIAL_MODIFIER_CD":"F7","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"943.29","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"72146","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"E3","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"58.47","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"49180","HCPCS_INITIAL_MODIFIER_CD":"X4","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"74.88","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"92134","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"161.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"11057","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"97124","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"472","PSPS_SUBMITTED_CHARGE_AMT":"15571.64","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"472","PSPS_DENIED_CHARGE_AMT":"15571.64","PSPS_ASSIGNED_SERVICES_CNT":"472","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99204","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"54","PSPS_SUBMITTED_CHARGE_AMT":"21136","PSPS_ALLOWED_CHARGE_AMT":"6702.9","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"54","PSPS_NCH_PAYMENT_AMT":"4626.99","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"87088","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"15.86","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1F"},{"HCPCS_CD":"31629","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"16","PSPS_SUBMITTED_CHARGE_AMT":"23766","PSPS_ALLOWED_CHARGE_AMT":"3020.11","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"16","PSPS_NCH_PAYMENT_AMT":"2439.31","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8F"},{"HCPCS_CD":"33859","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"18965.83","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"72070","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"73.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"70491","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"167.97","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2A"},{"HCPCS_CD":"A4450","HCPCS_INITIAL_MODIFIER_CD":"AV","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"25","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"160","PSPS_SUBMITTED_CHARGE_AMT":"28.8","PSPS_ALLOWED_CHARGE_AMT":"14.4","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"160","PSPS_NCH_PAYMENT_AMT":"11.28","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"12001","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"73.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"28272","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"T2","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"98.03","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"22510","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"204.55","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"28270","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"736.72","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"75625","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"J2248","HCPCS_INITIAL_MODIFIER_CD":"GY","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"17013","PRICING_LOCALITY_CD":"14","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"700","PSPS_SUBMITTED_CHARGE_AMT":"4900.91","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"700","PSPS_DENIED_CHARGE_AMT":"4900.91","PSPS_ASSIGNED_SERVICES_CNT":"700","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"71275","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"161.84","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"77263","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"906","PSPS_SUBMITTED_CHARGE_AMT":"602754.08","PSPS_ALLOWED_CHARGE_AMT":"148784.48","PSPS_DENIED_SERVICES_CNT":"21","PSPS_DENIED_CHARGE_AMT":"14429.77","PSPS_ASSIGNED_SERVICES_CNT":"906","PSPS_NCH_PAYMENT_AMT":"118529.41","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P7A"},{"HCPCS_CD":"G2010","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"7.39","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"33362","HCPCS_INITIAL_MODIFIER_CD":"62","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"Q0","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"671.96","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"99310","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"38","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"763","PSPS_SUBMITTED_CHARGE_AMT":"228874.18","PSPS_ALLOWED_CHARGE_AMT":"105196.52","PSPS_DENIED_SERVICES_CNT":"74","PSPS_DENIED_CHARGE_AMT":"21419.77","PSPS_ASSIGNED_SERVICES_CNT":"763","PSPS_NCH_PAYMENT_AMT":"82563.27","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"35566","HCPCS_INITIAL_MODIFIER_CD":"82","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"194.02","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"27691","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":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"6043.4","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"62223","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"370.15","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"67570","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1912.9","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"G8961","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"0.11","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"11","PSPS_DENIED_CHARGE_AMT":"0.11","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"J7328","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"672","PSPS_SUBMITTED_CHARGE_AMT":"4804.8","PSPS_ALLOWED_CHARGE_AMT":"1462.8","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"672","PSPS_NCH_PAYMENT_AMT":"1152.69","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"99218","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"82.22","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"60220","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"579.27","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"31645","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"20","PSPS_SUBMITTED_CHARGE_AMT":"14770","PSPS_ALLOWED_CHARGE_AMT":"1049.94","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"20","PSPS_NCH_PAYMENT_AMT":"847.98","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8F"},{"HCPCS_CD":"20692","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"905.3","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"J0185","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"50960","PSPS_SUBMITTED_CHARGE_AMT":"356720","PSPS_ALLOWED_CHARGE_AMT":"97072.82","PSPS_DENIED_SERVICES_CNT":"1820","PSPS_DENIED_CHARGE_AMT":"12740","PSPS_ASSIGNED_SERVICES_CNT":"50960","PSPS_NCH_PAYMENT_AMT":"75368.72","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"12042","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"87.65","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"67550","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"433.46","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"97605","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"21.68","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"20552","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"21","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"CR","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"64.97","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"99441","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"169.94","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"77295","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1984","PSPS_SUBMITTED_CHARGE_AMT":"1331774.74","PSPS_ALLOWED_CHARGE_AMT":"443475.93","PSPS_DENIED_SERVICES_CNT":"60","PSPS_DENIED_CHARGE_AMT":"47680.32","PSPS_ASSIGNED_SERVICES_CNT":"1984","PSPS_NCH_PAYMENT_AMT":"352007.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P7A"},{"HCPCS_CD":"J7042","HCPCS_INITIAL_MODIFIER_CD":"RH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"64721","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"24","PSPS_SUBMITTED_CHARGE_AMT":"103465","PSPS_ALLOWED_CHARGE_AMT":"7194.1","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"24","PSPS_NCH_PAYMENT_AMT":"5658.11","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"86140","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"26","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"5.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"31631","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"183.35","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8F"},{"HCPCS_CD":"99443","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"36","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"364.15","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"13133","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"102.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"73660","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"T5","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"52.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"81001","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"03602","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1201","PSPS_SUBMITTED_CHARGE_AMT":"18622.65","PSPS_ALLOWED_CHARGE_AMT":"3442.62","PSPS_DENIED_SERVICES_CNT":"115","PSPS_DENIED_CHARGE_AMT":"1233.5","PSPS_ASSIGNED_SERVICES_CNT":"1201","PSPS_NCH_PAYMENT_AMT":"3420.61","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1C"},{"HCPCS_CD":"52700","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"02102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"490.4","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"73706","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"78.64","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"99222","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"AI","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"217.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"G0442","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"17","PSPS_SUBMITTED_CHARGE_AMT":"1275","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"17","PSPS_DENIED_CHARGE_AMT":"1275","PSPS_ASSIGNED_SERVICES_CNT":"17","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"70487","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"2960","PSPS_ALLOWED_CHARGE_AMT":"586.69","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"474.71","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2A"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"61","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"485.51","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"G8907","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"73110","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"37","PSPS_SUBMITTED_CHARGE_AMT":"1065","PSPS_ALLOWED_CHARGE_AMT":"316.44","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"37","PSPS_NCH_PAYMENT_AMT":"227.22","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"54360","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"660.6","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"37215","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"802.36","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"51720","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"3663","PSPS_ALLOWED_CHARGE_AMT":"468.82","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"367.62","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P7B"},{"HCPCS_CD":"75989","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"196.17","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"67900","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"377.96","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"36482","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"6675.93","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"80048","HCPCS_INITIAL_MODIFIER_CD":"Q4","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"28","PSPS_SUBMITTED_CHARGE_AMT":"1680","PSPS_ALLOWED_CHARGE_AMT":"219.96","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"28","PSPS_NCH_PAYMENT_AMT":"218.26","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1B"},{"HCPCS_CD":"3078F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"C7","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"32557","HCPCS_INITIAL_MODIFIER_CD":"52","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"135.45","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"11043","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"D4","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"183.68","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"5","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"49500","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":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"245.88","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"64450","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"90750","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"24","PSPS_SUBMITTED_CHARGE_AMT":"4800.4","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"24","PSPS_DENIED_CHARGE_AMT":"4800.4","PSPS_ASSIGNED_SERVICES_CNT":"24","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1G"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1097","PSPS_SUBMITTED_CHARGE_AMT":"396876.64","PSPS_ALLOWED_CHARGE_AMT":"103252.85","PSPS_DENIED_SERVICES_CNT":"42","PSPS_DENIED_CHARGE_AMT":"15155.5","PSPS_ASSIGNED_SERVICES_CNT":"1097","PSPS_NCH_PAYMENT_AMT":"80682.64","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"42104","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"109.19","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"31536","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"12","PSPS_SUBMITTED_CHARGE_AMT":"5409","PSPS_ALLOWED_CHARGE_AMT":"2423.64","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"12","PSPS_NCH_PAYMENT_AMT":"1893.64","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8H"},{"HCPCS_CD":"99283","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M3"},{"HCPCS_CD":"29898","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"66.59","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8A"},{"HCPCS_CD":"67825","HCPCS_INITIAL_MODIFIER_CD":"E1","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"103.63","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"0449T","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"57","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"4200.44","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"20251","HCPCS_INITIAL_MODIFIER_CD":"51","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"196.14","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"11055","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"Q8","PSPS_SUBMITTED_SERVICE_CNT":"51","PSPS_SUBMITTED_CHARGE_AMT":"4317.93","PSPS_ALLOWED_CHARGE_AMT":"3622.19","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"51","PSPS_NCH_PAYMENT_AMT":"2671.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"67912","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"187.83","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"76881","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"23","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"190.5","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3F"},{"HCPCS_CD":"70030","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"82746","HCPCS_INITIAL_MODIFIER_CD":"91","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"93015","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"150","PSPS_SUBMITTED_CHARGE_AMT":"56070","PSPS_ALLOWED_CHARGE_AMT":"10963.5","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"150","PSPS_NCH_PAYMENT_AMT":"8595.6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2B"},{"HCPCS_CD":"95810","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"3732.26","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"73700","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"52","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"41","PSPS_SUBMITTED_CHARGE_AMT":"6356","PSPS_ALLOWED_CHARGE_AMT":"1972.45","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"41","PSPS_NCH_PAYMENT_AMT":"1450.83","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"L1902","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"37","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"103","PSPS_SUBMITTED_CHARGE_AMT":"16345.97","PSPS_ALLOWED_CHARGE_AMT":"7474.39","PSPS_DENIED_SERVICES_CNT":"28","PSPS_DENIED_CHARGE_AMT":"4237.88","PSPS_ASSIGNED_SERVICES_CNT":"103","PSPS_NCH_PAYMENT_AMT":"5737.01","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"99221","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"248.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"73590","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"J4","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"1125F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"18","PSPS_SUBMITTED_CHARGE_AMT":"0.14","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"18","PSPS_DENIED_CHARGE_AMT":"0.14","PSPS_ASSIGNED_SERVICES_CNT":"18","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"25825","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","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"78.21","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"23075","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"124.03","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"29130","HCPCS_INITIAL_MODIFIER_CD":"F5","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"20.08","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"24342","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"81","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"83.53","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"99318","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"72.27","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"99231","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"61.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"28306","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2424.9","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"90471","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"04312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1G"},{"HCPCS_CD":"99202","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"70.97","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"31259","HCPCS_INITIAL_MODIFIER_CD":"51","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"222.97","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8I"},{"HCPCS_CD":"62305","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"31","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"697.86","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"01924","HCPCS_INITIAL_MODIFIER_CD":"QZ","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GV","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"211.53","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"21601","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1052.54","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"99307","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"96542","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"58.92","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1D"},{"HCPCS_CD":"A0426","HCPCS_INITIAL_MODIFIER_CD":"EH","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"456.07","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1A"},{"HCPCS_CD":"J2357","HCPCS_INITIAL_MODIFIER_CD":"JW","PROVIDER_SPEC_CD":"03","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"270","PSPS_SUBMITTED_CHARGE_AMT":"18900","PSPS_ALLOWED_CHARGE_AMT":"10133.01","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"270","PSPS_NCH_PAYMENT_AMT":"8061.61","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"J9312","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"3294","PSPS_SUBMITTED_CHARGE_AMT":"1420330.02","PSPS_ALLOWED_CHARGE_AMT":"290071.1","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"3294","PSPS_NCH_PAYMENT_AMT":"229466.06","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1D"},{"HCPCS_CD":"98925","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"02102","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"33.41","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"G8428","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"126","PSPS_SUBMITTED_CHARGE_AMT":"0","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"126","PSPS_DENIED_CHARGE_AMT":"0","PSPS_ASSIGNED_SERVICES_CNT":"126","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"E0245","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1E"},{"HCPCS_CD":"0011A","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"60","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"47.13","PSPS_HCPCS_ASC_IND_CD":"","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":""},{"HCPCS_CD":"29825","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"12","PSPS_SUBMITTED_CHARGE_AMT":"32376","PSPS_ALLOWED_CHARGE_AMT":"3283.75","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"12","PSPS_NCH_PAYMENT_AMT":"2651.64","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8A"},{"HCPCS_CD":"93260","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"35.24","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"77067","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"A6","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"32.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1C"},{"HCPCS_CD":"73562","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"Q6","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"14.73","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"92228","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"31.48","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"72120","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"FY","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"19.27","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"64483","HCPCS_INITIAL_MODIFIER_CD":"SG","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":"RT","PSPS_SUBMITTED_SERVICE_CNT":"84","PSPS_SUBMITTED_CHARGE_AMT":"64762.32","PSPS_ALLOWED_CHARGE_AMT":"32783.94","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"84","PSPS_NCH_PAYMENT_AMT":"25439.48","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"11403","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"15.33","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"15220","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"577.95","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"96365","HCPCS_INITIAL_MODIFIER_CD":"Q1","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"67.08","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"93306","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"78","PSPS_SUBMITTED_CHARGE_AMT":"52095","PSPS_ALLOWED_CHARGE_AMT":"12537.91","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"78","PSPS_NCH_PAYMENT_AMT":"9740.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3C"},{"HCPCS_CD":"67041","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"320.26","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4C"},{"HCPCS_CD":"36228","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"200.74","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"96377","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"15.33","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"28047","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"91","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"945.79","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"54700","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"61783","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"03302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"73565","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"55","PSPS_SUBMITTED_CHARGE_AMT":"6655","PSPS_ALLOWED_CHARGE_AMT":"2243.16","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"55","PSPS_NCH_PAYMENT_AMT":"1693.49","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"72141","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":"23","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"63.38","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"92285","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"61","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5C"},{"HCPCS_CD":"99238","HCPCS_INITIAL_MODIFIER_CD":"GT","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"46.8","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"99204","HCPCS_INITIAL_MODIFIER_CD":"AI","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"97","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"99.38","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"36466","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"27","PSPS_SUBMITTED_CHARGE_AMT":"99900","PSPS_ALLOWED_CHARGE_AMT":"47613.25","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"27","PSPS_NCH_PAYMENT_AMT":"36520.44","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"68440","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"25.67","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"84100","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"20605","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"41","PSPS_SUBMITTED_CHARGE_AMT":"4173.38","PSPS_ALLOWED_CHARGE_AMT":"1083.63","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"41","PSPS_NCH_PAYMENT_AMT":"738.43","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"73610","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"20.22","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"49326","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"154.73","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"73600","HCPCS_INITIAL_MODIFIER_CD":"AQ","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"24.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"T6","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"61.58","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"G8420","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"76604","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"D3","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"23.08","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3F"},{"HCPCS_CD":"11622","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"01312","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"138.5","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"74019","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"19.92","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"64640","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"25.8","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99358","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"73221","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"162.62","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"E1390","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"QH","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"D1C"},{"HCPCS_CD":"36561","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"300.81","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8F"},{"HCPCS_CD":"99152","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"13292","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"11.99","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"10060","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"C6","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"101.45","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"46040","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"28","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"330.53","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"99349","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"CR","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"111.02","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4A"},{"HCPCS_CD":"90846","HCPCS_INITIAL_MODIFIER_CD":"GT","PROVIDER_SPEC_CD":"26","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"89.84","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"99443","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"386.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"98967","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"608.6","PSPS_ALLOWED_CHARGE_AMT":"367.9","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"270.26","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"26615","HCPCS_INITIAL_MODIFIER_CD":"FA","PROVIDER_SPEC_CD":"24","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"230.62","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"85651","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"828","PSPS_SUBMITTED_CHARGE_AMT":"17872.08","PSPS_ALLOWED_CHARGE_AMT":"3390.38","PSPS_DENIED_SERVICES_CNT":"34","PSPS_DENIED_CHARGE_AMT":"718.27","PSPS_ASSIGNED_SERVICES_CNT":"828","PSPS_NCH_PAYMENT_AMT":"3357.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"65755","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2678.42","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4A"},{"HCPCS_CD":"74425","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"138.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"20605","HCPCS_INITIAL_MODIFIER_CD":"LT","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":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"29.66","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"32555","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"X4","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"200.1","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"67042","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"892.09","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4C"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"25","PSPS_SUBMITTED_SERVICE_CNT":"255","PSPS_SUBMITTED_CHARGE_AMT":"36167.79","PSPS_ALLOWED_CHARGE_AMT":"17834.58","PSPS_DENIED_SERVICES_CNT":"20","PSPS_DENIED_CHARGE_AMT":"2344.6","PSPS_ASSIGNED_SERVICES_CNT":"254","PSPS_NCH_PAYMENT_AMT":"13526.2","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"52356","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"666.03","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"72070","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"23","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"20","PSPS_SUBMITTED_CHARGE_AMT":"2580","PSPS_ALLOWED_CHARGE_AMT":"667.47","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"20","PSPS_NCH_PAYMENT_AMT":"532.78","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"G2089","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1746","PSPS_SUBMITTED_CHARGE_AMT":"3.46","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"1746","PSPS_DENIED_CHARGE_AMT":"3.46","PSPS_ASSIGNED_SERVICES_CNT":"1738","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"23","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"277.53","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"80050","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"57","PSPS_SUBMITTED_CHARGE_AMT":"4854","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"57","PSPS_DENIED_CHARGE_AMT":"4854","PSPS_ASSIGNED_SERVICES_CNT":"57","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"99285","HCPCS_INITIAL_MODIFIER_CD":"CS","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"24","PSPS_SUBMITTED_SERVICE_CNT":"30","PSPS_SUBMITTED_CHARGE_AMT":"29700","PSPS_ALLOWED_CHARGE_AMT":"5096.17","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"30","PSPS_NCH_PAYMENT_AMT":"5099.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M3"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"12","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"57","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"60.41","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"42415","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"CR","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"69.19","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"A4617","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"18003","PRICING_LOCALITY_CD":"45","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1C"},{"HCPCS_CD":"71046","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"XP","PSPS_SUBMITTED_SERVICE_CNT":"26","PSPS_SUBMITTED_CHARGE_AMT":"1591","PSPS_ALLOWED_CHARGE_AMT":"299","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"26","PSPS_NCH_PAYMENT_AMT":"239.32","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1A"},{"HCPCS_CD":"11720","HCPCS_INITIAL_MODIFIER_CD":"Q7","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"XS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"11.96","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"93662","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"CS","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"143.22","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"27894","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"99152","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"15","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"42.15","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"70551","HCPCS_INITIAL_MODIFIER_CD":"MH","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1555.65","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2C"},{"HCPCS_CD":"4040F","HCPCS_INITIAL_MODIFIER_CD":"8P","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"37","PSPS_SUBMITTED_CHARGE_AMT":"0.37","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"37","PSPS_DENIED_CHARGE_AMT":"0.37","PSPS_ASSIGNED_SERVICES_CNT":"37","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"11603","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"86.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"63055","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1332.18","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1F"},{"HCPCS_CD":"92250","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"J7","TYPE_OF_SERVICE_CD":"Q","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"32.54","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5C"},{"HCPCS_CD":"73600","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"J6","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"27.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"6030F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"0","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"14","PSPS_DENIED_CHARGE_AMT":"0","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"69209","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"12.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"A6530","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1A"},{"HCPCS_CD":"92134","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"39","PSPS_SUBMITTED_CHARGE_AMT":"5538","PSPS_ALLOWED_CHARGE_AMT":"889.02","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"39","PSPS_NCH_PAYMENT_AMT":"632.15","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1293","PSPS_SUBMITTED_CHARGE_AMT":"197396.47","PSPS_ALLOWED_CHARGE_AMT":"98184.27","PSPS_DENIED_SERVICES_CNT":"36","PSPS_DENIED_CHARGE_AMT":"7752.27","PSPS_ASSIGNED_SERVICES_CNT":"1293","PSPS_NCH_PAYMENT_AMT":"68575.92","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"52341","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"689.32","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8E"},{"HCPCS_CD":"12021","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"114.13","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"93971","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"289.28","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3F"},{"HCPCS_CD":"67911","HCPCS_INITIAL_MODIFIER_CD":"E4","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2909.18","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"70","PSPS_SUBMITTED_CHARGE_AMT":"10915","PSPS_ALLOWED_CHARGE_AMT":"5421.33","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"70","PSPS_NCH_PAYMENT_AMT":"3468.19","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"28305","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"38.24","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"51729","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"98.59","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"UNK","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":""},{"HCPCS_CD":"33949","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"07102","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"534.66","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"49553","HCPCS_INITIAL_MODIFIER_CD":"59","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":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"150.7","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"J9190","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"27","PSPS_SUBMITTED_CHARGE_AMT":"298.06","PSPS_ALLOWED_CHARGE_AMT":"40.82","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"27","PSPS_NCH_PAYMENT_AMT":"8.29","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"O1D"},{"HCPCS_CD":"99203","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"80","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"36556","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"75.39","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"93923","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"47","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"12","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"165.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"99441","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"147","PSPS_SUBMITTED_CHARGE_AMT":"8959","PSPS_ALLOWED_CHARGE_AMT":"3259.74","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"147","PSPS_NCH_PAYMENT_AMT":"2530.09","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"20600","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"226.49","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"27524","HCPCS_INITIAL_MODIFIER_CD":"GC","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2006.94","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"20606","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"50.62","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4C"},{"HCPCS_CD":"10004","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"36475","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"C3","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"8274.76","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"71260","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04212","PRICING_LOCALITY_CD":"05","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"Q6","PSPS_SUBMITTED_SERVICE_CNT":"57","PSPS_SUBMITTED_CHARGE_AMT":"11974.39","PSPS_ALLOWED_CHARGE_AMT":"3295.68","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"57","PSPS_NCH_PAYMENT_AMT":"2606.88","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"67.63","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"11044","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"262.58","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"45397","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1639.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"92202","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"11.57","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"28124","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"TA","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"185.84","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"97010","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GY","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"0","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"14","PSPS_DENIED_CHARGE_AMT":"0","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"90832","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"80","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1782","PSPS_SUBMITTED_CHARGE_AMT":"160125.42","PSPS_ALLOWED_CHARGE_AMT":"84379.76","PSPS_DENIED_SERVICES_CNT":"148","PSPS_DENIED_CHARGE_AMT":"13549.78","PSPS_ASSIGNED_SERVICES_CNT":"1782","PSPS_NCH_PAYMENT_AMT":"67396.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"73502","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"56","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"44388","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"59.34","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"62362","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"72","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"149.24","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"29828","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"23","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"22","PSPS_SUBMITTED_CHARGE_AMT":"52233.6","PSPS_ALLOWED_CHARGE_AMT":"9786.48","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"22","PSPS_NCH_PAYMENT_AMT":"7843.98","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"97110","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"09302","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"95","PSPS_SUBMITTED_SERVICE_CNT":"104","PSPS_SUBMITTED_CHARGE_AMT":"3306.89","PSPS_ALLOWED_CHARGE_AMT":"2381.1","PSPS_DENIED_SERVICES_CNT":"14","PSPS_DENIED_CHARGE_AMT":"436.27","PSPS_ASSIGNED_SERVICES_CNT":"104","PSPS_NCH_PAYMENT_AMT":"1877.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"87634","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"597","PSPS_SUBMITTED_CHARGE_AMT":"89550","PSPS_ALLOWED_CHARGE_AMT":"772.2","PSPS_DENIED_SERVICES_CNT":"586","PSPS_DENIED_CHARGE_AMT":"87900","PSPS_ASSIGNED_SERVICES_CNT":"597","PSPS_NCH_PAYMENT_AMT":"772.2","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"83880","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"69","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"81","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"45","PSPS_SUBMITTED_CHARGE_AMT":"8039.25","PSPS_ALLOWED_CHARGE_AMT":"1727.44","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"45","PSPS_NCH_PAYMENT_AMT":"1714.01","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GV","PSPS_SUBMITTED_SERVICE_CNT":"23","PSPS_SUBMITTED_CHARGE_AMT":"4056","PSPS_ALLOWED_CHARGE_AMT":"2688.93","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"23","PSPS_NCH_PAYMENT_AMT":"2085.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"00940","HCPCS_INITIAL_MODIFIER_CD":"QK","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"P3","PSPS_SUBMITTED_SERVICE_CNT":"23","PSPS_SUBMITTED_CHARGE_AMT":"33552","PSPS_ALLOWED_CHARGE_AMT":"1851.55","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"23","PSPS_NCH_PAYMENT_AMT":"1472.39","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"73610","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"L3935","HCPCS_INITIAL_MODIFIER_CD":"KX","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"22852","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"69209","HCPCS_INITIAL_MODIFIER_CD":"79","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"10.39","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"73610","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"03602","PRICING_LOCALITY_CD":"21","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"52332","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"232.62","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8E"},{"HCPCS_CD":"17110","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"D7","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"275.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"36216","HCPCS_INITIAL_MODIFIER_CD":"XS","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"342.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"76775","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"21.98","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3B"},{"HCPCS_CD":"45385","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"208.2","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"G0108","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"31","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"GV","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"645.57","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"20680","HCPCS_INITIAL_MODIFIER_CD":"F5","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"62.31","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"19284","HCPCS_INITIAL_MODIFIER_CD":"XE","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":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"42.06","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1A"},{"HCPCS_CD":"99223","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"158.61","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"L8000","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"51","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"32.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"96372","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"72","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"742","PSPS_SUBMITTED_CHARGE_AMT":"37353.22","PSPS_ALLOWED_CHARGE_AMT":"9312.14","PSPS_DENIED_SERVICES_CNT":"36","PSPS_DENIED_CHARGE_AMT":"1906.07","PSPS_ASSIGNED_SERVICES_CNT":"742","PSPS_NCH_PAYMENT_AMT":"6802.23","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99238","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"27","PSPS_SUBMITTED_CHARGE_AMT":"5118","PSPS_ALLOWED_CHARGE_AMT":"1919.06","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"27","PSPS_NCH_PAYMENT_AMT":"1531.68","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"46050","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"140.31","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"G8432","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"36","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"27685","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"372.91","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"64455","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"106.91","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"0207T","HCPCS_INITIAL_MODIFIER_CD":"GA","PROVIDER_SPEC_CD":"41","CARRIER_NUM":"05202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"32557","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1146.51","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"21282","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"04","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"864.6","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"01844","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"32","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"P3","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"544.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"11603","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"68.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"99211","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"18.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"27829","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"58","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"264.1","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"72125","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"251","PSPS_SUBMITTED_CHARGE_AMT":"61785.5","PSPS_ALLOWED_CHARGE_AMT":"12781.19","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"251","PSPS_NCH_PAYMENT_AMT":"9617.28","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"95250","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"03202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"T1E"},{"HCPCS_CD":"11047","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"501.57","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"401","PSPS_SUBMITTED_CHARGE_AMT":"56197.9","PSPS_ALLOWED_CHARGE_AMT":"29396.95","PSPS_DENIED_SERVICES_CNT":"23","PSPS_DENIED_CHARGE_AMT":"4047","PSPS_ASSIGNED_SERVICES_CNT":"401","PSPS_NCH_PAYMENT_AMT":"21995.38","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"A6203","HCPCS_INITIAL_MODIFIER_CD":"A1","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"38","TYPE_OF_SERVICE_CD":"S","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"179","PSPS_SUBMITTED_CHARGE_AMT":"699.89","PSPS_ALLOWED_CHARGE_AMT":"453.56","PSPS_DENIED_SERVICES_CNT":"63","PSPS_DENIED_CHARGE_AMT":"246.33","PSPS_ASSIGNED_SERVICES_CNT":"179","PSPS_NCH_PAYMENT_AMT":"361.64","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1A"},{"HCPCS_CD":"29075","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"67.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"41100","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"46.16","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"22614","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"44.72","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"99282","HCPCS_INITIAL_MODIFIER_CD":"57","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"37.83","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M3"},{"HCPCS_CD":"99152","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"37.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"J9206","HCPCS_INITIAL_MODIFIER_CD":"JW","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"78","PSPS_SUBMITTED_CHARGE_AMT":"4668.92","PSPS_ALLOWED_CHARGE_AMT":"175.25","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"78","PSPS_NCH_PAYMENT_AMT":"133.68","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1D"},{"HCPCS_CD":"99483","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"10017","PSPS_ALLOWED_CHARGE_AMT":"2206.26","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"1765.54","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M6"},{"HCPCS_CD":"99238","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"12","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"18","PSPS_SUBMITTED_CHARGE_AMT":"4899.66","PSPS_ALLOWED_CHARGE_AMT":"1227.74","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"18","PSPS_NCH_PAYMENT_AMT":"992.85","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"93000","HCPCS_INITIAL_MODIFIER_CD":"XE","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"32.84","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2A"},{"HCPCS_CD":"49568","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"9418.2","PSPS_ALLOWED_CHARGE_AMT":"3501.12","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"2830.53","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1196","PSPS_SUBMITTED_CHARGE_AMT":"93661.2","PSPS_ALLOWED_CHARGE_AMT":"65455.04","PSPS_DENIED_SERVICES_CNT":"86","PSPS_DENIED_CHARGE_AMT":"7440.68","PSPS_ASSIGNED_SERVICES_CNT":"1196","PSPS_NCH_PAYMENT_AMT":"48551.53","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"29130","HCPCS_INITIAL_MODIFIER_CD":"F2","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"27517","HCPCS_INITIAL_MODIFIER_CD":"54","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"519.85","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"20937","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"97862.5","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"11","PSPS_DENIED_CHARGE_AMT":"97862.5","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"65222","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"93","CARRIER_NUM":"14112","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"40.8","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"29879","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"09202","PRICING_LOCALITY_CD":"20","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"8438.01","PSPS_ALLOWED_CHARGE_AMT":"8437.71","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"6633.96","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8A"},{"HCPCS_CD":"J7324","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"330.27","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"GT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"16.69","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"L3762","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"13","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"682.74","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"99215","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GV","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"74246","HCPCS_INITIAL_MODIFIER_CD":"","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"53.65","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"I1D"},{"HCPCS_CD":"G0249","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"28","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"53.55","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"J3301","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"04112","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"672","PSPS_SUBMITTED_CHARGE_AMT":"2352.2","PSPS_ALLOWED_CHARGE_AMT":"881.15","PSPS_DENIED_SERVICES_CNT":"68","PSPS_DENIED_CHARGE_AMT":"188.4","PSPS_ASSIGNED_SERVICES_CNT":"672","PSPS_NCH_PAYMENT_AMT":"686.29","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"36833","HCPCS_INITIAL_MODIFIER_CD":"78","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"71","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1135.67","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"73220","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"MH","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"33.36","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"22853","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"14","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"225.9","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"00914","HCPCS_INITIAL_MODIFIER_CD":"QY","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"X4","PSPS_SUBMITTED_SERVICE_CNT":"12","PSPS_SUBMITTED_CHARGE_AMT":"20937.5","PSPS_ALLOWED_CHARGE_AMT":"1323.13","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"12","PSPS_NCH_PAYMENT_AMT":"1063.34","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"73090","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"42.84","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"29828","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"80","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"52.78","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"99442","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"89","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"259","PSPS_SUBMITTED_CHARGE_AMT":"18274","PSPS_ALLOWED_CHARGE_AMT":"11195.65","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"259","PSPS_NCH_PAYMENT_AMT":"8387.13","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"95870","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"B4","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"132.6","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"96365","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"71","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"26","PSPS_SUBMITTED_CHARGE_AMT":"3575","PSPS_ALLOWED_CHARGE_AMT":"1140.75","PSPS_DENIED_SERVICES_CNT":"11","PSPS_DENIED_CHARGE_AMT":"1512.5","PSPS_ASSIGNED_SERVICES_CNT":"26","PSPS_NCH_PAYMENT_AMT":"885.39","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"A5500","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"55","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"07","TYPE_OF_SERVICE_CD":"J","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"58","PSPS_SUBMITTED_CHARGE_AMT":"7789.77","PSPS_ALLOWED_CHARGE_AMT":"4136.72","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"58","PSPS_NCH_PAYMENT_AMT":"3230.44","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"99201","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"07302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"40.29","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"99406","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"06102","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"50","PSPS_SUBMITTED_CHARGE_AMT":"1914","PSPS_ALLOWED_CHARGE_AMT":"603.52","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"50","PSPS_NCH_PAYMENT_AMT":"591.65","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"99153","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"15102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"23","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"49440","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2023.97","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6D"},{"HCPCS_CD":"36558","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"39","CARRIER_NUM":"06302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"44","PSPS_SUBMITTED_CHARGE_AMT":"169928","PSPS_ALLOWED_CHARGE_AMT":"10391.45","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"44","PSPS_NCH_PAYMENT_AMT":"8272.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"11312","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"103.81","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"10021","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"11302","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"46.41","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6D"},{"HCPCS_CD":"99326","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"100.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"44121","HCPCS_INITIAL_MODIFIER_CD":"52","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":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"804.81","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"81003","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2.2","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1C"},{"HCPCS_CD":"29550","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"T3","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"20605","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"02202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"29","PSPS_SUBMITTED_CHARGE_AMT":"5559.5","PSPS_ALLOWED_CHARGE_AMT":"1629.94","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"29","PSPS_NCH_PAYMENT_AMT":"1151.04","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"33285","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"61.79","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"67908","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"499.86","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"73562","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"66","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"135.9","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"44799","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"780.73","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"85018","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"769.58","PSPS_ALLOWED_CHARGE_AMT":"16.59","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"16.59","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1D"},{"HCPCS_CD":"50728","HCPCS_INITIAL_MODIFIER_CD":"22","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"312.83","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"J9250","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"20","PSPS_SUBMITTED_CHARGE_AMT":"12","PSPS_ALLOWED_CHARGE_AMT":"4.7","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"20","PSPS_NCH_PAYMENT_AMT":"3.68","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1D"},{"HCPCS_CD":"J9035","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"62.72","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1E"},{"HCPCS_CD":"43235","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"109.09","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8B"},{"HCPCS_CD":"74018","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"94","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"77","PSPS_SUBMITTED_SERVICE_CNT":"17","PSPS_SUBMITTED_CHARGE_AMT":"677","PSPS_ALLOWED_CHARGE_AMT":"170.51","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"17","PSPS_NCH_PAYMENT_AMT":"137.67","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"45380","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"2000F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"05302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"12002","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"197.52","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"75891","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"12302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"XU","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"48.21","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"E0140","HCPCS_INITIAL_MODIFIER_CD":"RR","PROVIDER_SPEC_CD":"A6","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"R","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"KI","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"142.18","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1E"},{"HCPCS_CD":"73620","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"90.32","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"G0446","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"126.49","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"64479","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"05402","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"102.08","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"99024","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"7133","PSPS_SUBMITTED_CHARGE_AMT":"9.42","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"7133","PSPS_DENIED_CHARGE_AMT":"9.42","PSPS_ASSIGNED_SERVICES_CNT":"7133","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"66185","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"851.68","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"G9707","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"02402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"64493","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"14412","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"40","PSPS_SUBMITTED_CHARGE_AMT":"52160","PSPS_ALLOWED_CHARGE_AMT":"5617.95","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"40","PSPS_NCH_PAYMENT_AMT":"4344.62","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"44799","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"L5701","HCPCS_INITIAL_MODIFIER_CD":"K4","PROVIDER_SPEC_CD":"56","CARRIER_NUM":"16013","PRICING_LOCALITY_CD":"39","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2641.16","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1F"},{"HCPCS_CD":"51705","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"13282","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"75.61","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"99308","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"24","PSPS_SUBMITTED_CHARGE_AMT":"3912","PSPS_ALLOWED_CHARGE_AMT":"1369.08","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"24","PSPS_NCH_PAYMENT_AMT":"1097.46","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M4B"},{"HCPCS_CD":"31257","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"831.2","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8I"},{"HCPCS_CD":"13121","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"07","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"337.11","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"G8427","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"61","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"0.13","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"13","PSPS_DENIED_CHARGE_AMT":"0.13","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"73070","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"FX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"12.96","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"25310","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":"22","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"380.71","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"90847","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"80","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"T","PLACE_OF_SERVICE_CD":"99","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"63.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5B"},{"HCPCS_CD":"01630","HCPCS_INITIAL_MODIFIER_CD":"QY","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"19","PSPS_SUBMITTED_CHARGE_AMT":"70755.03","PSPS_ALLOWED_CHARGE_AMT":"3042.82","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"19","PSPS_NCH_PAYMENT_AMT":"2442.56","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"99211","HCPCS_INITIAL_MODIFIER_CD":"Q6","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"35.76","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"99204","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"25","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"154.05","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1A"},{"HCPCS_CD":"99213","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"73630","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"A4","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"114.03","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"74420","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"354","PSPS_SUBMITTED_CHARGE_AMT":"71303.88","PSPS_ALLOWED_CHARGE_AMT":"8248.07","PSPS_DENIED_SERVICES_CNT":"59","PSPS_DENIED_CHARGE_AMT":"12160.63","PSPS_ASSIGNED_SERVICES_CNT":"352","PSPS_NCH_PAYMENT_AMT":"6580.88","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"23430","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":"59","PSPS_SUBMITTED_SERVICE_CNT":"20","PSPS_SUBMITTED_CHARGE_AMT":"35287.52","PSPS_ALLOWED_CHARGE_AMT":"1061","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"20","PSPS_NCH_PAYMENT_AMT":"819.21","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"36558","HCPCS_INITIAL_MODIFIER_CD":"51","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"11","PSPS_SUBMITTED_CHARGE_AMT":"27903.2","PSPS_ALLOWED_CHARGE_AMT":"1808.73","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"11","PSPS_NCH_PAYMENT_AMT":"1447.54","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"G0179","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"891","PSPS_SUBMITTED_CHARGE_AMT":"38609.26","PSPS_ALLOWED_CHARGE_AMT":"30429.74","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"891","PSPS_NCH_PAYMENT_AMT":"24361.06","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"31630","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"78","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"199.91","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8F"},{"HCPCS_CD":"00902","HCPCS_INITIAL_MODIFIER_CD":"QX","PROVIDER_SPEC_CD":"43","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"P3","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"56405","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"11","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"94.14","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"34710","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"310.93","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"77001","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"F3","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"XP","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"14.81","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"G0444","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"12502","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"02","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"31","PSPS_SUBMITTED_CHARGE_AMT":"775","PSPS_ALLOWED_CHARGE_AMT":"219.24","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"31","PSPS_NCH_PAYMENT_AMT":"219.24","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"31627","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"13102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"14","PSPS_SUBMITTED_CHARGE_AMT":"58860","PSPS_ALLOWED_CHARGE_AMT":"1476.72","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"14","PSPS_NCH_PAYMENT_AMT":"1185.95","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8F"},{"HCPCS_CD":"44160","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"807.72","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1B"},{"HCPCS_CD":"97110","HCPCS_INITIAL_MODIFIER_CD":"GO","PROVIDER_SPEC_CD":"65","CARRIER_NUM":"01212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"158.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"20550","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"19","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"50.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"99223","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"C7","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"18","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"167.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"36222","HCPCS_INITIAL_MODIFIER_CD":"50","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"17","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"553.85","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I4B"},{"HCPCS_CD":"G0283","HCPCS_INITIAL_MODIFIER_CD":"GP","PROVIDER_SPEC_CD":"20","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"562","PSPS_SUBMITTED_CHARGE_AMT":"30678.5","PSPS_ALLOWED_CHARGE_AMT":"5637.98","PSPS_DENIED_SERVICES_CNT":"34","PSPS_DENIED_CHARGE_AMT":"1957","PSPS_ASSIGNED_SERVICES_CNT":"562","PSPS_NCH_PAYMENT_AMT":"4207.98","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"01925","HCPCS_INITIAL_MODIFIER_CD":"AA","PROVIDER_SPEC_CD":"05","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2096.1","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P0"},{"HCPCS_CD":"92610","HCPCS_INITIAL_MODIFIER_CD":"GN","PROVIDER_SPEC_CD":"15","CARRIER_NUM":"15202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"546.62","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"26540","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"F4","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5B"},{"HCPCS_CD":"67950","HCPCS_INITIAL_MODIFIER_CD":"XU","PROVIDER_SPEC_CD":"18","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"RT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1837.1","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"99223","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"17","CARRIER_NUM":"07202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"61","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"163.32","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"71275","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"A1","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"129.06","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"86704","HCPCS_INITIAL_MODIFIER_CD":"Q1","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"47.72","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"45380","HCPCS_INITIAL_MODIFIER_CD":"52","PROVIDER_SPEC_CD":"02","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"12.33","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8D"},{"HCPCS_CD":"99235","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"566.02","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"99236","HCPCS_INITIAL_MODIFIER_CD":"A1","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"11502","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"GC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"174.75","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2B"},{"HCPCS_CD":"94060","HCPCS_INITIAL_MODIFIER_CD":"CC","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"89","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"72142","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":"11","HCPCS_SECOND_MODIFIER_CD":"MH","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"73.69","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"11721","HCPCS_INITIAL_MODIFIER_CD":"Q8","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"33","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"154","PSPS_SUBMITTED_CHARGE_AMT":"9192","PSPS_ALLOWED_CHARGE_AMT":"6807","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"154","PSPS_NCH_PAYMENT_AMT":"3603.37","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"70330","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"10312","PRICING_LOCALITY_CD":"35","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"27.82","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"99219","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"06","CARRIER_NUM":"14512","PRICING_LOCALITY_CD":"50","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M2A"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"40","CARRIER_NUM":"12202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"138","PSPS_SUBMITTED_CHARGE_AMT":"19188","PSPS_ALLOWED_CHARGE_AMT":"7173.02","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"138","PSPS_NCH_PAYMENT_AMT":"5023.21","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"63012","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"120.3","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"63276","HCPCS_INITIAL_MODIFIER_CD":"GC","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1567.94","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"G8427","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"10","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"40808","HCPCS_INITIAL_MODIFIER_CD":"59","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"67.56","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"66985","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"49","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"F","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"773.8","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4B"},{"HCPCS_CD":"69200","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"199.4","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"62328","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"28","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"59","PSPS_SUBMITTED_CHARGE_AMT":"21240","PSPS_ALLOWED_CHARGE_AMT":"4242.08","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"59","PSPS_NCH_PAYMENT_AMT":"3416.5","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"70100","HCPCS_INITIAL_MODIFIER_CD":"FY","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"32.04","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"95861","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"13","CARRIER_NUM":"08102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"30117","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"59","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"446.37","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"0001A","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"01","CARRIER_NUM":"11402","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"60","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"47.13","PSPS_HCPCS_ASC_IND_CD":"","PSPS_ERROR_IND_CD":"4","HCPCS_BETOS_CD":""},{"HCPCS_CD":"12031","HCPCS_INITIAL_MODIFIER_CD":"GC","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"139.12","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6A"},{"HCPCS_CD":"20550","HCPCS_INITIAL_MODIFIER_CD":"58","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"08202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"79","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"47.38","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6B"},{"HCPCS_CD":"33264","HCPCS_INITIAL_MODIFIER_CD":"Q0","PROVIDER_SPEC_CD":"21","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"179.78","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P2F"},{"HCPCS_CD":"27882","HCPCS_INITIAL_MODIFIER_CD":"","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"3924","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"73221","HCPCS_INITIAL_MODIFIER_CD":"RT","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"10112","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"262.9","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2D"},{"HCPCS_CD":"57120","HCPCS_INITIAL_MODIFIER_CD":"80","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"189.68","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"25","PROVIDER_SPEC_CD":"77","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"GW","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"93.27","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"81003","HCPCS_INITIAL_MODIFIER_CD":"QW","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"20","HCPCS_SECOND_MODIFIER_CD":"GV","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2.25","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1C"},{"HCPCS_CD":"G0009","HCPCS_INITIAL_MODIFIER_CD":"GW","PROVIDER_SPEC_CD":"08","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"V","PLACE_OF_SERVICE_CD":"14","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"49.74","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1G"},{"HCPCS_CD":"E2603","HCPCS_INITIAL_MODIFIER_CD":"NU","PROVIDER_SPEC_CD":"54","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"KX","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"118.99","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1D"},{"HCPCS_CD":"J7612","HCPCS_INITIAL_MODIFIER_CD":"CR","PROVIDER_SPEC_CD":"A5","CARRIER_NUM":"19003","PRICING_LOCALITY_CD":"16","TYPE_OF_SERVICE_CD":"P","PLACE_OF_SERVICE_CD":"12","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1050","PSPS_SUBMITTED_CHARGE_AMT":"1277.61","PSPS_ALLOWED_CHARGE_AMT":"329.1","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"1050","PSPS_NCH_PAYMENT_AMT":"263.28","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"D1G"},{"HCPCS_CD":"11056","HCPCS_INITIAL_MODIFIER_CD":"Q9","PROVIDER_SPEC_CD":"48","CARRIER_NUM":"09102","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"13","HCPCS_SECOND_MODIFIER_CD":"T9","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"59","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5A"},{"HCPCS_CD":"73110","HCPCS_INITIAL_MODIFIER_CD":"AT","PROVIDER_SPEC_CD":"35","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"75","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"99212","HCPCS_INITIAL_MODIFIER_CD":"95","PROVIDER_SPEC_CD":"25","CARRIER_NUM":"13202","PRICING_LOCALITY_CD":"03","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"CC","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"40.5","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"77080","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"66","CARRIER_NUM":"05102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"81.77","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"74018","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"80.06","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1F"},{"HCPCS_CD":"47562","HCPCS_INITIAL_MODIFIER_CD":"AS","PROVIDER_SPEC_CD":"97","CARRIER_NUM":"01182","PRICING_LOCALITY_CD":"26","TYPE_OF_SERVICE_CD":"8","PLACE_OF_SERVICE_CD":"24","HCPCS_SECOND_MODIFIER_CD":"51","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"39.44","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P5E"},{"HCPCS_CD":"15733","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"91","CARRIER_NUM":"12402","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1921.72","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"71260","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"06202","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"ME","PSPS_SUBMITTED_SERVICE_CNT":"130","PSPS_SUBMITTED_CHARGE_AMT":"103610","PSPS_ALLOWED_CHARGE_AMT":"9638.76","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"130","PSPS_NCH_PAYMENT_AMT":"7633.39","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2B"},{"HCPCS_CD":"73000","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"63","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"32","HCPCS_SECOND_MODIFIER_CD":"LT","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"164.66","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I1B"},{"HCPCS_CD":"77306","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"92","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"6","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"589.06","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P7A"},{"HCPCS_CD":"70460","HCPCS_INITIAL_MODIFIER_CD":"TC","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"11202","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"324.21","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I2A"},{"HCPCS_CD":"99214","HCPCS_INITIAL_MODIFIER_CD":"24","PROVIDER_SPEC_CD":"33","CARRIER_NUM":"03502","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"83.36","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M1B"},{"HCPCS_CD":"A0425","HCPCS_INITIAL_MODIFIER_CD":"SS","PROVIDER_SPEC_CD":"59","CARRIER_NUM":"02302","PRICING_LOCALITY_CD":"01","TYPE_OF_SERVICE_CD":"D","PLACE_OF_SERVICE_CD":"41","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"49.9","PSPS_SUBMITTED_CHARGE_AMT":"374.25","PSPS_ALLOWED_CHARGE_AMT":"0","PSPS_DENIED_SERVICES_CNT":"49.9","PSPS_DENIED_CHARGE_AMT":"374.25","PSPS_ASSIGNED_SERVICES_CNT":"49.9","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1A"},{"HCPCS_CD":"0509F","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"01112","PRICING_LOCALITY_CD":"09","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Z2"},{"HCPCS_CD":"69209","HCPCS_INITIAL_MODIFIER_CD":"LT","PROVIDER_SPEC_CD":"50","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"86","PSPS_SUBMITTED_CHARGE_AMT":"3189.33","PSPS_ALLOWED_CHARGE_AMT":"877.04","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"86","PSPS_NCH_PAYMENT_AMT":"566.09","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P6C"},{"HCPCS_CD":"19085","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1A"},{"HCPCS_CD":"67921","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"2730.76","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P4E"},{"HCPCS_CD":"38746","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"04","CARRIER_NUM":"03402","PRICING_LOCALITY_CD":"02","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P1G"},{"HCPCS_CD":"23474","HCPCS_INITIAL_MODIFIER_CD":"50","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":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"1624.95","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P3D"},{"HCPCS_CD":"83690","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"10212","PRICING_LOCALITY_CD":"AX","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"6.75","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1H"},{"HCPCS_CD":"95822","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"29","CARRIER_NUM":"14212","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"21","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"50.08","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T2D"},{"HCPCS_CD":"G0438","HCPCS_INITIAL_MODIFIER_CD":"AF","PROVIDER_SPEC_CD":"11","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"13","PSPS_SUBMITTED_CHARGE_AMT":"4368","PSPS_ALLOWED_CHARGE_AMT":"1838.65","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"13","PSPS_NCH_PAYMENT_AMT":"1808.91","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"M5D"},{"HCPCS_CD":"J9145","HCPCS_INITIAL_MODIFIER_CD":"76","PROVIDER_SPEC_CD":"90","CARRIER_NUM":"14312","PRICING_LOCALITY_CD":"40","TYPE_OF_SERVICE_CD":"1","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"1430","PSPS_SUBMITTED_CHARGE_AMT":"128700","PSPS_ALLOWED_CHARGE_AMT":"78727.67","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"1430","PSPS_NCH_PAYMENT_AMT":"62502.14","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"O1D"},{"HCPCS_CD":"D9230","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"16","CARRIER_NUM":"03102","PRICING_LOCALITY_CD":"00","TYPE_OF_SERVICE_CD":"7","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"0","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"Y1"},{"HCPCS_CD":"88185","HCPCS_INITIAL_MODIFIER_CD":"","PROVIDER_SPEC_CD":"83","CARRIER_NUM":"00882","PRICING_LOCALITY_CD":"B4","TYPE_OF_SERVICE_CD":"5","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"101","PSPS_SUBMITTED_CHARGE_AMT":"13671","PSPS_ALLOWED_CHARGE_AMT":"2138.17","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"101","PSPS_NCH_PAYMENT_AMT":"1697.92","PSPS_HCPCS_ASC_IND_CD":"N","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"T1G"},{"HCPCS_CD":"76700","HCPCS_INITIAL_MODIFIER_CD":"26","PROVIDER_SPEC_CD":"30","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"A6","TYPE_OF_SERVICE_CD":"4","PLACE_OF_SERVICE_CD":"22","HCPCS_SECOND_MODIFIER_CD":"AQ","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"32.85","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"I3B"},{"HCPCS_CD":"52287","HCPCS_INITIAL_MODIFIER_CD":"GC","PROVIDER_SPEC_CD":"34","CARRIER_NUM":"04412","PRICING_LOCALITY_CD":"99","TYPE_OF_SERVICE_CD":"2","PLACE_OF_SERVICE_CD":"11","HCPCS_SECOND_MODIFIER_CD":"","PSPS_SUBMITTED_SERVICE_CNT":"","PSPS_SUBMITTED_CHARGE_AMT":"","PSPS_ALLOWED_CHARGE_AMT":"","PSPS_DENIED_SERVICES_CNT":"","PSPS_DENIED_CHARGE_AMT":"","PSPS_ASSIGNED_SERVICES_CNT":"","PSPS_NCH_PAYMENT_AMT":"569.9","PSPS_HCPCS_ASC_IND_CD":"Y","PSPS_ERROR_IND_CD":"0","HCPCS_BETOS_CD":"P8E"}]