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    <name>PED FLOURIDE TX</name>
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    <name>PED NOT COVERED DENTAL</name>
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    <name>PHYSICAL THERAPY</name>
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    <billing_code>97012</billing_code>
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  <out_of_network>
    <name>PHYSICAL THERAPY</name>
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    <name>PHYSICAL THERAPY</name>
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    <description>PSYTX W PT 60 MINUTES</description>
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      <service_code>10</service_code>
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        <billing_code_modifier></billing_code_modifier>
        <providers>
          <billed_charges>300.00</billed_charges>
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      <payments>
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    <name>TELEMEDICINE</name>
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    <billing_code_type_version>2020</billing_code_type_version>
    <description>PARTIAL HOSPITALIZATION SERV</description>
    <allowed_amounts>
      <tin>
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        <value>881815444</value>
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      <service_code>22</service_code>
      <billing_class>Institutional</billing_class>
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        <billing_code_modifier>95</billing_code_modifier>
        <providers>
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          <npi>1346984804</npi>
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  </out_of_network>
  <last_updated_on>2026-08-01</last_updated_on>
</root>
