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97732f74-96a1-4bb1-afbb-1545f50fc384.aspx
  
08.00.62nAbatacept(Orencia®)forInjectionforIntravenousUse08.00.62nPharmacy (08)Abatacept (Orencia®) for Injection for Intravenous Use97732f74-96a1-4bb1-afbb-1545f50fc3844255Abatacept (Orencia®) for Injection for Intravenous Use08.00.62
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12.00.01gAcupuncture(Independence)12.00.01gMiscellaneous (12)Acupuncture (Independence)151d34b6-4e58-416b-b105-5282cd83c5f43625Acupuncture (Independence)12.00.01
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12.04.04aAcuteCareFacilityInpatientTransfers12.04.04aMiscellaneous (12)Acute Care Facility Inpatient Transfersa26ef448-30db-43ac-94c2-e6d4b2be4b3a3272Acute Care Facility Inpatient Transfers12.04.04
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08.01.11gAdo-TrastuzumabEmtansine(Kadcyla®)08.01.11gPharmacy (08)Ado-Trastuzumab Emtansine (Kadcyla®)7d2c9273-a6c7-4c55-829b-131f19dcc5363832Ado-Trastuzumab Emtansine (Kadcyla®)08.01.11
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08.00.69cAgalsidasebeta(Fabrazyme®)08.00.69cPharmacy (08)Agalsidase beta (Fabrazyme®)8d58c8ea-0ea8-4718-8161-db431f914dfd4113Agalsidase beta (Fabrazyme®)08.00.69
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12.04.03cAirAmbulanceServices12.04.03cMiscellaneous (12)Air Ambulance Services225d3101-03b1-4bcf-bbb9-96b94e93d8973340Air Ambulance Services12.04.03
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07.00.21jAllergyImmunotherapy07.00.21jMedicine (07)Allergy Immunotherapyed39b1c3-6d7a-468f-a34f-d38ae5a9c7b93158Allergy Immunotherapy07.00.21
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08.01.88AllogeneicProcessedThymusTissue-agdc(Rethymic®)08.01.88Pharmacy (08)Allogeneic Processed Thymus Tissue-agdc (Rethymic®)87fbd717-0d87-4e63-b5c6-86d241ad32d64140Allogeneic Processed Thymus Tissue-agdc (Rethymic®)08.01.88
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06.02.29dAlloMap™MolecularExpressionTestingforHeartTransplantRejection(IndependenceAdministrators)06.02.29dPathology and Laboratory (06)AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)732b9ea2-3872-424f-a25a-816f8a28c5754137AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (Independence Administrators)06.02.29
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08.00.91eAlpha1-AntitrypsinTherapy(e.g.,Prolastin-C®,AralastNP®,Glassia®,Zemaira®)08.00.91ePharmacy (08)Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)cd609c07-1e33-4d4a-8c08-24fb11b0ecea4244Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP®, Glassia®, Zemaira®)08.00.91
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07.02.21hAmbulatoryElectrocardiography(AECG)MonitoringandMobileCardiacOutpatientTelemetry(MCOT)Monitoring07.02.21hMedicine (07)Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring4df933c3-6356-4ea5-b86d-a751cf0ba12b3909Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring07.02.21
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01.00.12AnesthesiaServicesforEpidural,ParavertebralFacetandSacroiliacJointInjectionsforSpinalJointManagement01.00.12Anesthesia (01)Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management9bdc47f8-e2e3-4abb-9b1d-1d4c1c5e2b744124Anesthesia Services for Epidural, Paravertebral Facet and Sacroiliac Joint Injections for Spinal Joint Management01.00.12
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08.01.82bAnifrolumab-fnia(Saphnelo™)08.01.82bPharmacy (08)Anifrolumab-fnia (Saphnelo™)2fdd9022-2641-49f8-ae4f-b09593402c694246Anifrolumab-fnia (Saphnelo™)08.01.82
cf9faf96-487d-47c2-bd76-bc70fd056a33.aspx
  
05.00.39rAnkle-Foot/Knee-Ankle-FootOrthoses05.00.39rDME (05)Ankle-Foot/Knee-Ankle-Foot Orthosescf9faf96-487d-47c2-bd76-bc70fd056a333409Ankle-Foot/Knee-Ankle-Foot Orthoses05.00.39
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06.03.04nApheresisTherapy06.03.04nPathology and Laboratory (06)Apheresis Therapy36aee0bb-d271-4e94-8256-eafdfce453972774Apheresis Therapy06.03.04
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11.08.05gApplicationandRemovalofTattoos11.08.05gSurgery (11)Application and Removal of Tattoosf0e9fbf8-0357-4a99-8c55-0e6a960173ce4193Application and Removal of Tattoos11.08.05
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08.01.41cAprepitant(Cinvanti™),FosaprepitantDimeglumine(Emend®),Granisetron(Sustol®),andRolapitant(Varubi®)08.01.41cPharmacy (08)Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)202addae-a8d3-482f-b7b2-e3af034fa3553470Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)08.01.41
{"3471": {"Id":3471,"MPAttachmentLetter":"A","Title":"Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents","MPPolicyAttachmentInternalSourceId":5660,"PolicyAttachmentPageName":"00411fd3-0b49-4077-9c80-e7d25e6698cf"},}
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11.05.16jAqueousShunts,Microstents,Viscocanalostomy,andCanaloplastyfortheTreatmentofGlaucoma11.05.16jSurgery (11)Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma05720d8e-7925-4a18-9aac-a0d2841e14153947Aqueous Shunts, Microstents, Viscocanalostomy, and Canaloplasty for the Treatment of Glaucoma11.05.16
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b0e984df-bd5e-4e0d-85e6-c2a0b64cb49d.aspx
  
11.14.19pArtificialIntervertebralCervicalDiscInsertion(IndependenceAdministrators)11.14.19pSurgery (11)Artificial Intervertebral Cervical Disc Insertion (Independence Administrators)b0e984df-bd5e-4e0d-85e6-c2a0b64cb49d3704Artificial Intervertebral Cervical  Disc Insertion (Independence Administrators)11.14.19
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11.15.31ArtificialIntervertebralLumbarDiscInsertion11.15.31Surgery (11)Artificial Intervertebral Lumbar Disc Insertion5d023597-bc1e-40ec-8616-4e86387f03a23666Artificial Intervertebral Lumbar Disc Insertion11.15.31
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08.01.35eAsparaginaseErwiniaChrysanthemi(Erwinaze®),asparaginaseerwiniachrysanthemi(recombinant)-rywn(Rylaze™)08.01.35ePharmacy (08)Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)f3236241-d962-4d30-8d8c-9d77386611ed3962Asparaginase Erwinia Chrysanthemi (Erwinaze®), asparaginase erwinia chrysanthemi (recombinant)-rywn (Rylaze™)08.01.35
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06.02.27nAssaysofGeneticExpressioninTumorTissueforBreastCancerPrognosis(IndependenceAdministrators)06.02.27nPathology and Laboratory (06)Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)8948609b-b11b-4d03-9ee4-a40ee508865c4257Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (Independence Administrators)06.02.27
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07.10.06iAssistedReproductiveTechnologyforInfertilityandOocyteCryopreservation07.10.06iMedicine (07)Assisted Reproductive Technology for Infertility and Oocyte Cryopreservationa27db102-bd23-420f-a9fd-c5c995a63b0a3779Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation07.10.06
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08.01.69bAtezolizumab(Tecentriq®)08.01.69bPharmacy (08)Atezolizumab (Tecentriq®)676d5b29-8a79-4b13-b40b-0c52774693ce4053Atezolizumab (Tecentriq®)08.01.69
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05.00.29lAutomaticExternalCardioverterDefibrillators(WearableandNonwearable)05.00.29lDME (05)Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)6e37e5d6-bbaf-48fa-a6c3-063563373e0a3492Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)05.00.29
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08.01.64aAvelumab(Bavencio®)08.01.64aPharmacy (08)Avelumab (Bavencio®)24beb3c0-be00-4c64-b472-cc607163e0e43955Avelumab (Bavencio®)08.01.64
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11.03.02tBariatricSurgery11.03.02tSurgery (11)Bariatric Surgerye2e22104-ada2-4d84-9c71-c600f1ea170e2791Bariatric Surgery11.03.02
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08.01.70bBelantamabmafodotin-blmf(Blenrep)08.01.70bPharmacy (08)Belantamab mafodotin-blmf (Blenrep)2a68daca-621e-4826-8bcf-e5212ad5e2c14215Belantamab mafodotin-blmf (Blenrep)08.01.70
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08.00.99dBelimumab(Benlysta®)forIntravenousUse08.00.99dPharmacy (08)Belimumab (Benlysta®) for Intravenous Use7d21a876-9c51-43f5-b1f2-8eee2bfcf3514042Belimumab (Benlysta®) for Intravenous Use08.00.99
167886b2-53f9-41fc-9978-48e3b5dcd96c.aspx
  
08.00.66qBevacizumab(Avastin®)andRelatedBiosimilarsForOncologicUse08.00.66qPharmacy (08)Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use167886b2-53f9-41fc-9978-48e3b5dcd96c4044Bevacizumab (Avastin®) and Related Biosimilars For Oncologic Use08.00.66
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00.10.39oBillingforProfessionalOffice-BasedServicesPerformedinanOutpatientOffice-BasedSettingLocatedwithinaFacilityoronaFacilityCampus00.10.39oAdministrative (00)Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus51aaf4af-1813-47af-95b8-8602dee4fdf03975Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus00.10.39
{"3976": {"Id":3976,"MPAttachmentLetter":"A","Title":"Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus","MPPolicyAttachmentInternalSourceId":6119,"PolicyAttachmentPageName":"9e4f9d52-c926-4fc8-81c9-1f2f4cc888d5"},}
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00.10.38aBillingRequirementsforMultipleBirthsforProfessionalProviders00.10.38aAdministrative (00)Billing Requirements for Multiple Births for Professional Providers7467b7be-328a-4664-89ab-13b4c08598393051Billing Requirements for Multiple Births for Professional Providers00.10.38
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bb4a7aab-8e51-48b8-b70e-d9723cca3441.aspx
  
11.05.02jBlepharoplasty,RepairofBlepharoptosis,RepairofBrowPtosis,andCanthoplasty/Canthopexy11.05.02jSurgery (11)Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexybb4a7aab-8e51-48b8-b70e-d9723cca34413770Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy11.05.02
{"3771": {"Id":3771,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5915,"PolicyAttachmentPageName":"bb9ab1fd-6bf0-4cdc-9739-4a2c84da817c"},}
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08.01.21eBlinatumomab(Blincyto®)08.01.21ePharmacy (08)Blinatumomab (Blincyto®)92a12a39-2356-431e-9323-ff9db3f3d0394314Blinatumomab (Blincyto®)08.01.21
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11.01.06fBone-Anchored(Osseointegrated)HearingAidsandImplantableMiddleEarHearingAids11.01.06fSurgery (11)Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aidscc074a4c-e78d-48cd-853e-9f582fa3102a3984Bone-Anchored (Osseointegrated) Hearing Aids and Implantable Middle Ear Hearing Aids11.01.06
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09.00.04lBoneMineralDensity(BMD)Testing09.00.04lRadiology (09)Bone Mineral Density (BMD) Testinge2d89fb6-24ef-4a16-a953-2d2451aaa4043911Bone Mineral Density (BMD) Testing09.00.04
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{"4128": {"Id":4128,"MPAttachmentLetter":"A","Title":"ICD-10 Codes and Narratives","MPPolicyAttachmentInternalSourceId":6196,"PolicyAttachmentPageName":"c0c4029d-6756-48a1-8034-abe6354ac88e"},}
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4cb3894b-2c2b-4737-a0c4-1ba6c6a65167.aspx
  
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{"4313": {"Id":4313,"MPAttachmentLetter":"A","Title":"ICD CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6279,"PolicyAttachmentPageName":"e7333c32-5c43-44e6-9c53-4f8eeb569931"},}
c2b28475-247f-463e-9c3b-5a6ecc89c4d0.aspx
  
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{"3673": {"Id":3673,"MPAttachmentLetter":"A","Title":"ICD-10 Codes","MPPolicyAttachmentInternalSourceId":5729,"PolicyAttachmentPageName":"9edc8373-3d61-4d0c-9158-b0716b073418"},}
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43d9008a-91ea-42cb-8a77-52594e9adc9f.aspx
  
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{"4300": {"Id":4300,"MPAttachmentLetter":"A","Title":"Procedure Codes Related to Cast and Splint Applications and Associated Supplies","MPPolicyAttachmentInternalSourceId":6421,"PolicyAttachmentPageName":"ef40cfc7-9301-40ac-955b-042c21374443"},}
437e90bf-4f5d-44ae-ad6a-f798ebf1031e.aspx
  
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{"3933": {"Id":3933,"MPAttachmentLetter":"A","Title":"ICD 10 codes for policy 11.01.07d, Cataract Surgery","MPPolicyAttachmentInternalSourceId":6072,"PolicyAttachmentPageName":"599939d0-daf9-4f13-8d68-e4a1412ea6d6"},}
03ddb112-9c09-44e9-a171-b7205733aeaa.aspx
  
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c9c846c6-7feb-44a7-bccc-e1a79d2f0ddf.aspx
  
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07c40c18-7aef-4330-8935-16635f2ebf67.aspx
  
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{"3924": {"Id":3924,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":6115,"PolicyAttachmentPageName":"699d305b-2a53-480e-a300-2ca122f8de0d"},}
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587df3b8-62b9-4b9f-9077-c749915aa179.aspx
  
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28b7bded-e653-48c9-8ce4-55585b9d0a5a.aspx
  
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{"3842": {"Id":3842,"MPAttachmentLetter":"A","Title":"MEDICALLY NECESSARY ICD 10 CODES FOR COBALAMIN (VITAMIN B12) AND/OR FOLIC ACID TESTING (CPT CODES 82607, 82608, 82746, AND 82747)","MPPolicyAttachmentInternalSourceId":6108,"PolicyAttachmentPageName":"8bfa343e-fd32-44e5-bb8b-2708d310b6e4"},}
52e574a3-d754-4e64-ae47-a5d0662891ef.aspx
  
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b13222a3-3284-42ca-b079-b34f15e94d7a.aspx
  
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878f6379-6a66-4575-afb6-3c2568636bdd.aspx
  
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028a155c-ca0d-49b2-857b-420d23f28d40.aspx
  
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486b7833-e733-47e1-a5a2-1fb22d353084.aspx
  
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0e5a3246-799b-4df3-bc4a-9a5c0ec82166.aspx
  
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85256AA800623D7A852584710058EC0E.aspx
  
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a82f67db-980d-4c60-977b-e187fabb4e25.aspx
  
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08.01.29iDaratumumab(Darzalex®),Daratumumab,andHyaluronidase-fihj(DarzalexFaspro®)08.01.29iPharmacy (08)Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)c52b181a-c56d-458d-b762-7932fdcf89373289Daratumumab (Darzalex®), Daratumumab, and Hyaluronidase-fihj (Darzalex Faspro®)08.01.29
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e3eb36bf-27fc-4bb7-aff5-6392d35d8cfe.aspx
  
11.08.17kDebridementofMycoticandSymptomaticNon-MycoticHypertrophicToeNails11.08.17kSurgery (11)Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nailse3eb36bf-27fc-4bb7-aff5-6392d35d8cfe3609Debridement of Mycotic and Symptomatic Non-Mycotic Hypertrophic Toe Nails11.08.17
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5ca29d9a-b491-4574-8883-a34fa8efdba8.aspx
  
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f30d1c58-12ed-4dd7-804a-44b17a3f3141.aspx
  
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798cca7f-66bc-4a18-89fe-800f61ffd321.aspx
  
08.00.94pDenosumab(Prolia®,Xgeva®),Romosozumab-aqqg(Evenity®)08.00.94pPharmacy (08)Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)798cca7f-66bc-4a18-89fe-800f61ffd3214201Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity®)08.00.94
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04806458-c6be-4c07-9ca9-0fde63e8263b.aspx
  
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446bbd29-dbdd-4b22-9e4d-36459520ca1e.aspx
  
00.03.02acDiagnosticRadiologyServicesIncludedinCapitation00.03.02acAdministrative (00)Diagnostic Radiology Services Included in Capitation446bbd29-dbdd-4b22-9e4d-36459520ca1e3997Diagnostic Radiology Services Included in Capitation00.03.02
{"3998": {"Id":3998,"MPAttachmentLetter":"A","Title":"Diagnostic Radiology Procedure Codes Included in Capitation for Pennsylvania (PA) Health Maintenance Organization (HMO) Members","MPPolicyAttachmentInternalSourceId":6155,"PolicyAttachmentPageName":"b5a08986-de39-403a-8a4b-0fc9ce6f7f1e"},}
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00.09.01iDirectAccesstoObstetrics/Gynecology(OB/GYN)Services00.09.01iAdministrative (00)Direct Access to Obstetrics/Gynecology (OB/GYN) Servicesf1e8356b-0be8-4ff2-ab3e-8a379e2b76493994Direct Access to Obstetrics/Gynecology (OB/GYN) Services00.09.01
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0eff6641-5ea6-4e5f-9173-3c37553a1fbf.aspx
  
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