{ "reporting_entity_name": "Centene Management Company LLC", "reporting_entity_type": "Third Party Administrator", "version": "1.0.0", "last_updated_on": "2026-05-04", "out_of_network": [{ "name": "PHARMACY", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "250", "description": "PHARMACY - GENERAL CLASSIFICATION", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420504780" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 564.00, "providers": [{ "billed_charge": 1879.90, "npi": [1083708226] } ] } ] } ] }, { "name": "IV THERAPY", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "260", "description": "IV THERAPY - GENERAL CLASSIFICATION", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420504780" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 8536.67, "providers": [{ "billed_charge": 14969.70, "npi": [1083708226] } ] } ] }, { "tin": { "type": "ein", "value": "421019872" }, "service_code": ["23", "21"], "billing_class": "institutional", "payments": [{ "allowed_amount": 1590.40, "providers": [{ "billed_charge": 1590.40, "npi": [1962594622] } ] }, { "allowed_amount": 1055.15, "providers": [{ "billed_charge": 3403.70, "npi": [1962594622] } ] } ] } ] }, { "name": "LABORATORY", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "300", "description": "LABORATORY - GENERAL CLASSIFICATION", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420868216" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 2013.06, "providers": [{ "billed_charge": 3887.10, "npi": [1265402390] } ] } ] }, { "tin": { "type": "ein", "value": "420504780" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 1204.85, "providers": [{ "billed_charge": 1943.59, "npi": [1083708226] } ] } ] }, { "tin": { "type": "ein", "value": "426004813" }, "service_code": ["22", "23", "21"], "billing_class": "institutional", "payments": [{ "allowed_amount": 1946.38, "providers": [{ "billed_charge": 7739.00, "npi": [1699541870] } ] }, { "allowed_amount": 9034.00, "providers": [{ "billed_charge": 12151.00, "npi": [1699541870] } ] }, { "allowed_amount": 4565.12, "providers": [{ "billed_charge": 11845.00, "npi": [1376544320] } ] }, { "allowed_amount": 5871.40, "providers": [{ "billed_charge": 19457.00, "npi": [1376544320] } ] }, { "allowed_amount": 2604.00, "providers": [{ "billed_charge": 163866.00, "npi": [1376544320] } ] } ] }, { "tin": { "type": "ein", "value": "470484764" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 2869.74, "providers": [{ "billed_charge": 14865.00, "npi": [1265517759] } ] } ] } ] }, { "name": "LAB/CHEMISTRY", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "301", "description": "LABORATORY - CHEMISTRY", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420504780" }, "service_code": ["22", "23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 4545.33, "providers": [{ "billed_charge": 8716.86, "npi": [1083708226] } ] }, { "allowed_amount": 59.14, "providers": [{ "billed_charge": 320.50, "npi": [1083708226] } ] } ] }, { "tin": { "type": "ein", "value": "426039708" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 272.24, "providers": [{ "billed_charge": 444.00, "npi": [1588636351] } ] } ] }, { "tin": { "type": "ein", "value": "421019872" }, "service_code": ["23", "21"], "billing_class": "institutional", "payments": [{ "allowed_amount": 2642.53, "providers": [{ "billed_charge": 2642.53, "npi": [1962594622] } ] }, { "allowed_amount": 2444.50, "providers": [{ "billed_charge": 2935.37, "npi": [1962594622] } ] } ] } ] }, { "name": "LAB/HEMATOLOGY", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "305", "description": "LABORATORY - HEMATOLOGY", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420504780" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 832.12, "providers": [{ "billed_charge": 1379.28, "npi": [1083708226] } ] } ] } ] }, { "name": "LAB/BACT-MIRCO", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "306", "description": "LABORATORY - BACTERIOLOGY & MICROBIOLOGY", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420504780" }, "service_code": ["22", "23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 565.95, "providers": [{ "billed_charge": 961.36, "npi": [1083708226] } ] }, { "allowed_amount": 16.72, "providers": [{ "billed_charge": 96.44, "npi": [1083708226] } ] } ] } ] }, { "name": "LAB/UROLOGY", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "307", "description": "LABORATORY - UROLOGY", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420504780" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 62.66, "providers": [{ "billed_charge": 128.56, "npi": [1083708226] } ] } ] } ] }, { "name": "EMERG ROOM", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "450", "description": "EMERGENCY ROOM - GENERAL CLASSIFICATION", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420504780" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 30679.33, "providers": [{ "billed_charge": 63874.70, "npi": [1083708226] } ] } ] }, { "tin": { "type": "ein", "value": "421019872" }, "service_code": ["23", "21"], "billing_class": "institutional", "payments": [{ "allowed_amount": 6028.89, "providers": [{ "billed_charge": 11300.81, "npi": [1962594622] } ] }, { "allowed_amount": 1218.81, "providers": [{ "billed_charge": 1218.81, "npi": [1962594622] } ] } ] }, { "tin": { "type": "ein", "value": "470484764" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 7650.76, "providers": [{ "billed_charge": 18138.00, "npi": [1265517759] } ] } ] }, { "tin": { "type": "ein", "value": "426004813" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 23798.97, "providers": [{ "billed_charge": 38541.00, "npi": [1376544320] } ] } ] } ] }, { "name": "DRUG/DETAIL CODE", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "636", "description": "DRUGS REQ SPEC IDENTIFICATION - DRUGS REQ DETAILED CODING*", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420504780" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 2764.76, "providers": [{ "billed_charge": 9125.85, "npi": [1083708226] } ] } ] }, { "tin": { "type": "ein", "value": "421019872" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 601.80, "providers": [{ "billed_charge": 1958.00, "npi": [1962594622] } ] } ] }, { "tin": { "type": "ein", "value": "470484764" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 776.98, "providers": [{ "billed_charge": 2589.85, "npi": [1265517759] } ] } ] }, { "tin": { "type": "ein", "value": "426004813" }, "service_code": ["23"], "billing_class": "institutional", "payments": [{ "allowed_amount": 1466.47, "providers": [{ "billed_charge": 4888.17, "npi": [1376544320] } ] }, { "allowed_amount": 176.51, "providers": [{ "billed_charge": 588.35, "npi": [1699541870] } ] } ] } ] }, { "name": "X-RAY EXAM CHEST 2 VIEWS", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "71046", "description": "RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["22", "23"], "billing_class": "professional", "payments": [{ "allowed_amount": 7.67, "providers": [{ "billed_charge": 29.00, "npi": [1234567893] } ] }, { "allowed_amount": 15.37, "providers": [{ "billed_charge": 58.00, "npi": [1234567893] } ] } ] } ] }, { "name": "BREAST TOMOSYNTHESIS BI", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "77063", "description": "SCREENING DIGITAL BREAST TOMOSYNTHESIS, BILATERAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY P", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["22"], "billing_class": "professional", "payments": [{ "allowed_amount": 596.35, "providers": [{ "billed_charge": 2413.00, "npi": [1234567893] } ] } ] } ] }, { "name": "SCR MAMMO BI INCL CAD", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "77067", "description": "SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["22"], "billing_class": "professional", "payments": [{ "allowed_amount": 776.15, "providers": [{ "billed_charge": 2954.00, "npi": [1234567893] } ] } ] } ] }, { "name": "CYTOPATH C/V AUTO FLUID REDO", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "88175", "description": "CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY RPTNG SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED TH", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420680452" }, "service_code": ["81"], "billing_class": "professional", "payments": [{ "allowed_amount": 42.58, "providers": [{ "billed_charge": 68.00, "npi": [1962485136] } ] } ] } ] }, { "name": "TISSUE EXAM BY PATHOLOGIST", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "88305", "description": "LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ABORTION - SPONTANEOUS/MISSED ARTER", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["22"], "billing_class": "professional", "payments": [{ "allowed_amount": 170.11, "providers": [{ "billed_charge": 1504.40, "npi": [1234567893] } ] } ] } ] }, { "name": "PSYTX W PT 60 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "90837", "description": "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT", "allowed_amounts": [{ "tin": { "type": "ein", "value": "420680411" }, "service_code": ["53", "10"], "billing_class": "professional", "payments": [{ "allowed_amount": 110.68, "providers": [{ "billed_charge": 250.00, "npi": [1578913950] } ] }, { "allowed_amount": 123.67, "providers": [{ "billed_charge": 250.00, "npi": [1578913950] } ] } ] }, { "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11", "10"], "billing_class": "professional", "payments": [{ "allowed_amount": 979.14, "providers": [{ "billed_charge": 1140.00, "npi": [1234567893] } ] }, { "allowed_amount": 6933.05, "providers": [{ "billed_charge": 9934.90, "npi": [1234567893] } ] } ] } ] }, { "name": "ELECTRIC STIMULATION THERAPY", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "97014", "description": "APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (UNATTENDED)", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 129.51, "providers": [{ "billed_charge": 331.00, "npi": [1234567893] } ] } ] } ] }, { "name": "THERAPEUTIC EXERCISES", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "97110", "description": "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH A", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 1253.60, "providers": [{ "billed_charge": 4683.00, "npi": [1234567893] } ] } ] } ] }, { "name": "NEUROMUSCULAR REEDUCATION", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "97112", "description": "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALA", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 424.45, "providers": [{ "billed_charge": 1387.00, "npi": [1234567893] } ] } ] } ] }, { "name": "MANUAL THERAPY 1/> REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "97140", "description": "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTIO", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 831.46, "providers": [{ "billed_charge": 3248.00, "npi": [1234567893] } ] } ] } ] }, { "name": "THERAPEUTIC ACTIVITIES", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "97530", "description": "THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FU", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 598.70, "providers": [{ "billed_charge": 1866.00, "npi": [1234567893] } ] } ] } ] }, { "name": "CHIROPRACT MANJ 1-2 REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "98940", "description": "CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 1-2 REGIONS", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 1114.02, "providers": [{ "billed_charge": 2415.00, "npi": [1234567893] } ] } ] } ] }, { "name": "CHIROPRACT MANJ 3-4 REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "98941", "description": "CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 3-4 REGIONS", "allowed_amounts": [{ "tin": { "type": "ein", "value": "833574817" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 68.75, "providers": [{ "billed_charge": 110.00, "npi": [1134696008] } ] } ] }, { "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 16740.44, "providers": [{ "billed_charge": 26480.20, "npi": [1234567893] } ] } ] } ] }, { "name": "CHIROPRACT MANJ XTRSPINL 1/>", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "98943", "description": "CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); EXTRASPINAL, 1 OR MORE REGIONS", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 601.54, "providers": [{ "billed_charge": 779.00, "npi": [1234567893] } ] } ] } ] }, { "name": "OFFICE/OUTPATIENT VISIT NEW", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "99203", "description": "OFFICE OR OTH OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES TH", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11"], "billing_class": "professional", "payments": [{ "allowed_amount": 192.95, "providers": [{ "billed_charge": 470.00, "npi": [1234567893] } ] } ] } ] }, { "name": "OFFICE/OUTPATIENT VISIT EST", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "99213", "description": "OFFICE OR OTH OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH RE", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["22", "11"], "billing_class": "professional", "payments": [{ "allowed_amount": 60.36, "providers": [{ "billed_charge": 167.00, "npi": [1234567893] } ] }, { "allowed_amount": 3136.13, "providers": [{ "billed_charge": 6766.06, "npi": [1234567893] } ] } ] } ] }, { "name": "OFFICE/OUTPATIENT VISIT EST", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "99214", "description": "OFFICE OR OTH OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH RE", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["11", "22", "02", "53", "10"], "billing_class": "professional", "payments": [{ "allowed_amount": 75.51, "providers": [{ "billed_charge": 184.00, "npi": [1234567893] } ] }, { "allowed_amount": 3716.02, "providers": [{ "billed_charge": 7608.22, "npi": [1234567893] } ] }, { "allowed_amount": 177.66, "providers": [{ "billed_charge": 358.00, "npi": [1234567893] } ] }, { "allowed_amount": 606.91, "providers": [{ "billed_charge": 1268.00, "npi": [1234567893] } ] }, { "allowed_amount": 207.90, "providers": [{ "billed_charge": 412.00, "npi": [1234567893] } ] } ] } ] }, { "name": "INITIAL HOSPITAL CARE", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "99223", "description": "INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["22"], "billing_class": "professional", "payments": [{ "allowed_amount": 143.02, "providers": [{ "billed_charge": 1230.00, "npi": [1234567893] } ] } ] } ] }, { "name": "SUBSEQUENT HOSPITAL CARE", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "99232", "description": "SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["22", "61", "51", "21"], "billing_class": "professional", "payments": [{ "allowed_amount": 1716.79, "providers": [{ "billed_charge": 12658.00, "npi": [1234567893] } ] }, { "allowed_amount": 66.92, "providers": [{ "billed_charge": 500.00, "npi": [1234567893] } ] }, { "allowed_amount": 210.65, "providers": [{ "billed_charge": 1700.00, "npi": [1234567893] } ] }, { "allowed_amount": 122.84, "providers": [{ "billed_charge": 400.00, "npi": [1234567893] } ] } ] } ] }, { "name": "EMERGENCY DEPT VISIT", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "99284", "description": "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KE", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["23"], "billing_class": "professional", "payments": [{ "allowed_amount": 5261.01, "providers": [{ "billed_charge": 41007.00, "npi": [1234567893] } ] } ] } ] }, { "name": "EMERGENCY DEPT VISIT", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "99285", "description": "EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KE", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["23"], "billing_class": "professional", "payments": [{ "allowed_amount": 9155.86, "providers": [{ "billed_charge": 81363.00, "npi": [1234567893] } ] } ] } ] }, { "name": "GRND MLGE PER STATUTE MILE", "billing_code_type": "HCPCS", "billing_code_type_version": "2022", "billing_code": "A0425", "description": "GROUND MILEAGE, PER STATUTE MILE", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["41"], "billing_class": "professional", "payments": [{ "allowed_amount": 4420.66, "providers": [{ "billed_charge": 11239.28, "npi": [1234567893] } ] } ] } ] }, { "name": "AMB SVC ALS ER TRNSPRT LVL1", "billing_code_type": "HCPCS", "billing_code_type_version": "2022", "billing_code": "A0427", "description": "AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["41"], "billing_class": "professional", "payments": [{ "allowed_amount": 8230.34, "providers": [{ "billed_charge": 15417.10, "npi": [1234567893] } ] } ] } ] }, { "name": "AMB SERVICE BLS EMERGENCY TR", "billing_code_type": "HCPCS", "billing_code_type_version": "2022", "billing_code": "A0429", "description": "AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS, EMERGENCY)", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["41"], "billing_class": "professional", "payments": [{ "allowed_amount": 3870.72, "providers": [{ "billed_charge": 7828.11, "npi": [1234567893] } ] } ] } ] }, { "name": "NEG PRSS WND TX PUMP STATN", "billing_code_type": "HCPCS", "billing_code_type_version": "2022", "billing_code": "E2402", "description": "NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE", "allowed_amounts": [{ "tin": { "type": "ein", "value": "999999999" }, "service_code": ["12"], "billing_class": "professional", "payments": [{ "allowed_amount": 4092.00, "providers": [{ "billed_charge": 12039.50, "npi": [1234567893] } ] } ] } ] } ] }