| Allowed Amount | Billed Charge |
|---|---|
| $48.32 | $491.67 |
| $102.07 | $1,038.66 |
| $114.36 | $1,163.80 |
| $128.92 | $1,311.92 |
| $152.01 | $1,546.85 |
| $173.66 | $1,767.22 |
| $289.27 | $2,943.68 |
| $308.56 | $3,140.00 |
| $354.37 | $3,606.16 |
| $536.55 | $5,460.12 |
| $552.05 | $5,617.80 |
| $687.74 | $6,998.65 |
| $694.50 | $7,067.40 |
| $772.58 | $7,862.00 |
| $773.88 | $7,875.23 |
| $810.63 | $8,249.26 |
| $1,250.40 | $12,724.49 |
| $1,260.28 | $12,825.00 |
| $1,567.22 | $15,948.46 |
| $1,818.55 | $18,506.08 |
| $2,657.15 | $27,040.00 |
| $4,297.09 | $43,728.49 |
| $4,515.98 | $45,956.00 |
| $5,751.99 | $58,534.00 |
| $6,140.92 | $62,492.14 |
| Allowed Amount | Billed Charge |
|---|---|
| $95.00 | $95 |
| Allowed Amount | Billed Charge |
|---|---|
| $95.00 | $95 |
| Allowed Amount | Billed Charge |
|---|---|
| $0.20 | $0.2 |
| $0.29 | $0.29 |
| $0.48 | $0.48 |
| $0.64 | $0.64 |
| $0.73 | $0.73 |
| $0.74 | $0.74 |
| $0.83 | $0.83 |
| $0.90 | $0.9 |
| $0.99 | $0.99 |
| $1.13 | $1.13 |
| $1.42 | $1.42 |
| $2.62 | $2.62 |
| $2.71 | $18.05 |
| $3.77 | $3.77 |
| $14.70 | $98.02 |
| $22.69 | $22.69 |
| $25.52 | $25.52 |
| $27.97 | $186.5 |
| $28.20 | $188 |
| $84.49 | $563.3 |
| $97.19 | $647.98 |
| $100.10 | $667.4 |
| $116.09 | $774 |
| $187.49 | $1,250.00 |
| $209.72 | $209.72 |
| $252.69 | $1,684.68 |
| $312.32 | $312.32 |
| $375.28 | $2,502.00 |
| $592.22 | $3,948.38 |
| $594.33 | $3,962.43 |
| $615.11 | $4,101.00 |
| $662.81 | $4,419.00 |
| $835.90 | $5,572.96 |
| $907.15 | $6,048.00 |
| $1,138.94 | $7,593.40 |
| $1,403.59 | $9,357.70 |
| Allowed Amount | Billed Charge |
|---|---|
| $16.92 | $142.5 |
| $34.92 | $294.06 |
| $56.15 | $472.78 |
| $56.27 | $473.84 |
| $87.29 | $735 |
| $92.09 | $775.4 |
| $153.91 | $1,295.96 |
| $158.36 | $1,333.45 |
| $171.79 | $1,446.50 |
| $261.69 | $2,203.50 |
| $273.95 | $2,306.80 |
| $366.85 | $3,089.00 |
| $399.09 | $3,360.50 |
| $414.64 | $3,491.40 |
| $431.10 | $3,630.00 |
| $454.45 | $3,826.69 |
| $460.55 | $3,878.00 |
| $542.08 | $4,564.55 |
| $610.94 | $5,144.34 |
| $717.78 | $6,044.00 |
| $788.17 | $6,636.72 |
| $857.32 | $7,219.00 |
| $1,126.64 | $9,486.78 |
| $1,542.11 | $12,985.21 |
| $2,118.07 | $17,835.00 |
| $2,305.47 | $19,413.00 |
| $4,227.97 | $35,601.16 |
| $5,531.54 | $46,577.74 |
| $5,958.97 | $50,176.94 |
| $6,101.74 | $51,379.08 |
| $16,442.83 | $138,455.30 |
| Allowed Amount | Billed Charge |
|---|---|
| $3.23 | $14.23 |
| $3.55 | $15.62 |
| $5.10 | $12.92 |
| $5.62 | $8.32 |
| $11.94 | $30.28 |
| $12.35 | $54.39 |
| $19.55 | $49.58 |
| $20.94 | $92.22 |
| $24.82 | $109.31 |
| $28.50 | $42.18 |
| $34.08 | $50.44 |
| $40.92 | $60.56 |
| $80.55 | $204.25 |
| $81.04 | $205.49 |
| $92.98 | $235.76 |
| $102.31 | $151.41 |
| $105.23 | $155.74 |
| $159.30 | $235.76 |
| $280.60 | $415.28 |
| $318.42 | $471.25 |
| $486.24 | $1,232.90 |
| $509.68 | $1,292.33 |
| $711.95 | $1,053.67 |
| $883.48 | $1,307.53 |
| $1,300.92 | $3,298.60 |
| $1,337.30 | $1,979.16 |
| $1,362.37 | $2,016.27 |
| $1,570.94 | $3,983.26 |
| $2,415.80 | $6,125.48 |
| $4,758.65 | $12,066.00 |
| $5,963.31 | $8,825.50 |