{"reporting_entity_name":"Centene Management Company LLC","reporting_entity_type":"Third Party Administrator","version":"2.0.0","last_updated_on":"2026-04-28","out_of_network":[{"name":"ROOM-BOARD/SEMI","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"120","description":"ROOM AND BOARD - SEMI PRIVATE TWO BED -GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["21"],"billing_class":"institutional","payments":[{"allowed_amount":107789.31,"providers":[{"billed_charge":125172.00,"npi":[1962579029]}]}]}]},{"name":"PHARMACY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"250","description":"PHARMACY - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"231352213"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":76.24,"providers":[{"billed_charge":1773.59,"npi":[1376339226]}]},{"allowed_amount":429.57,"providers":[{"billed_charge":1304.77,"npi":[1548293954]}]},{"allowed_amount":55.12,"providers":[{"billed_charge":204.88,"npi":[1013933175]}]},{"allowed_amount":83.33,"providers":[{"billed_charge":345.58,"npi":[1952399933]}]}]},{"tin":{"type":"ein","value":"231352203"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":347.22,"providers":[{"billed_charge":77.58,"npi":[1669405072]}]}]},{"tin":{"type":"ein","value":"231352166"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":53.04,"providers":[{"billed_charge":205.17,"npi":[1215921457]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":116.93,"providers":[{"billed_charge":1861.30,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"844475996"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":317.45,"providers":[{"billed_charge":261.41,"npi":[1073047981]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7.35,"providers":[{"billed_charge":33.85,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":56.38,"providers":[{"billed_charge":332.43,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":37.30,"providers":[{"billed_charge":549.47,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":19.96,"providers":[{"billed_charge":808.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":299.29,"providers":[{"billed_charge":2395.82,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":57.37,"providers":[{"billed_charge":197.48,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":390.15,"providers":[{"billed_charge":7622.51,"npi":[1437865953]}]},{"allowed_amount":21.41,"providers":[{"billed_charge":595.63,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":82.27,"providers":[{"billed_charge":538.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1935.33,"providers":[{"billed_charge":379.65,"npi":[1396194197]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":109.16,"providers":[{"billed_charge":2569.00,"npi":[1245335629]}]},{"allowed_amount":15.03,"providers":[{"billed_charge":605.00,"npi":[1215042114]}]},{"allowed_amount":6.73,"providers":[{"billed_charge":2781.00,"npi":[1508971441]}]}]},{"tin":{"type":"ein","value":"934487584"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":134.80,"providers":[{"billed_charge":535.65,"npi":[1699515304]}]}]}]},{"name":"DRUGS/INCIDNT RAD","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"255","description":"PHARMACY - DRUGS INCIDENT TO RADIOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":422.79,"providers":[{"billed_charge":4593.57,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":734.16,"providers":[{"billed_charge":1266.14,"npi":[1699734665]}]}]}]},{"name":"IV SOLUTIONS","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"258","description":"PHARMACY - IV SOLUTIONS","allowed_amounts":[{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4.65,"providers":[{"billed_charge":227.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":98.47,"providers":[{"billed_charge":756.28,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1.55,"providers":[{"billed_charge":157.50,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":10.73,"providers":[{"billed_charge":1045.00,"npi":[1508971441]}]},{"allowed_amount":1.55,"providers":[{"billed_charge":54.00,"npi":[1245335629]}]}]}]},{"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":"231352213"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3186.90,"providers":[{"billed_charge":10533.00,"npi":[1548293954]}]},{"allowed_amount":1906.71,"providers":[{"billed_charge":9610.00,"npi":[1952399933]}]},{"allowed_amount":1830.86,"providers":[{"billed_charge":3834.00,"npi":[1376339226]}]}]},{"tin":{"type":"ein","value":"231352203"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1720.23,"providers":[{"billed_charge":8670.00,"npi":[1669405072]}]}]},{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":732.54,"providers":[{"billed_charge":2566.00,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1636.92,"providers":[{"billed_charge":4410.00,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3972.69,"providers":[{"billed_charge":22861.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":13797.64,"providers":[{"billed_charge":64258.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4009.71,"providers":[{"billed_charge":9648.00,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":419.37,"providers":[{"billed_charge":3201.00,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"844475996"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":709.00,"providers":[{"billed_charge":2225.00,"npi":[1073047981]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1763.61,"providers":[{"billed_charge":10486.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4890.86,"providers":[{"billed_charge":16445.00,"npi":[1396194197]}]}]}]},{"name":"LABORATORY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"300","description":"LABORATORY - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"231352213"},"service_code":["22","23","20"],"billing_class":"institutional","payments":[{"allowed_amount":3277.01,"providers":[{"billed_charge":27872.00,"npi":[1952399933]}]},{"allowed_amount":3742.85,"providers":[{"billed_charge":33889.00,"npi":[1548293954]}]},{"allowed_amount":7029.98,"providers":[{"billed_charge":23966.00,"npi":[1376339226]}]},{"allowed_amount":936.47,"providers":[{"billed_charge":5674.00,"npi":[1013933175]}]},{"allowed_amount":164.69,"providers":[{"billed_charge":791.00,"npi":[1548293954]}]},{"allowed_amount":8.97,"providers":[{"billed_charge":149.00,"npi":[1013933175]}]}]},{"tin":{"type":"ein","value":"231352203"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2391.89,"providers":[{"billed_charge":28679.00,"npi":[1669405072]}]}]},{"tin":{"type":"ein","value":"231352166"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":2258.23,"providers":[{"billed_charge":28163.31,"npi":[1215921457]}]},{"allowed_amount":5811.64,"providers":[{"billed_charge":15692.49,"npi":[1215921457]}]}]},{"tin":{"type":"ein","value":"861248931"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":99.73,"providers":[{"billed_charge":3454.00,"npi":[1699340927]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":16944.55,"providers":[{"billed_charge":39923.02,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"844475996"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2093.49,"providers":[{"billed_charge":11650.00,"npi":[1073047981]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":1880.82,"providers":[{"billed_charge":5356.00,"npi":[1568435477]}]},{"allowed_amount":12.23,"providers":[{"billed_charge":49.00,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6.49,"providers":[{"billed_charge":25.50,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23","20"],"billing_class":"institutional","payments":[{"allowed_amount":2955.78,"providers":[{"billed_charge":20586.00,"npi":[1437182847]}]},{"allowed_amount":142.63,"providers":[{"billed_charge":1209.00,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"221494454"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":507.16,"providers":[{"billed_charge":5036.00,"npi":[1760488266]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":574.10,"providers":[{"billed_charge":1493.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2899.87,"providers":[{"billed_charge":14966.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2819.14,"providers":[{"billed_charge":44266.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":19.54,"providers":[{"billed_charge":413.00,"npi":[1265096069]}]},{"allowed_amount":1787.31,"providers":[{"billed_charge":25455.00,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":57.82,"providers":[{"billed_charge":312.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1667.92,"providers":[{"billed_charge":28509.00,"npi":[1396194197]}]}]},{"tin":{"type":"ein","value":"934487584"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2367.67,"providers":[{"billed_charge":10099.27,"npi":[1699515304]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":369.60,"providers":[{"billed_charge":1110.00,"npi":[1508971441]}]},{"allowed_amount":1015.77,"providers":[{"billed_charge":1641.00,"npi":[1215042114]}]},{"allowed_amount":1543.64,"providers":[{"billed_charge":3585.00,"npi":[1245335629]}]}]}]},{"name":"LAB/CHEMISTRY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"301","description":"LABORATORY - CHEMISTRY","allowed_amounts":[{"tin":{"type":"ein","value":"231352213"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":829.90,"providers":[{"billed_charge":2398.00,"npi":[1376339226]}]},{"allowed_amount":388.45,"providers":[{"billed_charge":2076.00,"npi":[1952399933]}]},{"allowed_amount":216.81,"providers":[{"billed_charge":2882.00,"npi":[1548293954]}]}]},{"tin":{"type":"ein","value":"231352203"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":333.95,"providers":[{"billed_charge":1932.00,"npi":[1669405072]}]}]},{"tin":{"type":"ein","value":"210634462"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":305.97,"providers":[{"billed_charge":343.00,"npi":[1568442309]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":10672.61,"providers":[{"billed_charge":22216.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"161165049"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":37.81,"providers":[{"billed_charge":231.00,"npi":[1518998699]}]}]},{"tin":{"type":"ein","value":"240795463"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":155.88,"providers":[{"billed_charge":3028.83,"npi":[1083614382]}]}]},{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1748.33,"providers":[{"billed_charge":3929.25,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":410.58,"providers":[{"billed_charge":2131.00,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1971.57,"providers":[{"billed_charge":13720.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1061.39,"providers":[{"billed_charge":2446.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7196.39,"providers":[{"billed_charge":343377.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"251260215"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":127.58,"providers":[{"billed_charge":869.00,"npi":[1578560504]}]}]},{"tin":{"type":"ein","value":"250965588"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":490.46,"providers":[{"billed_charge":3272.00,"npi":[1871594127]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":204.23,"providers":[{"billed_charge":2369.00,"npi":[1265096069]}]},{"allowed_amount":24.28,"providers":[{"billed_charge":368.00,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":2621.02,"providers":[{"billed_charge":6138.00,"npi":[1083615587]}]},{"allowed_amount":48.66,"providers":[{"billed_charge":250.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1636.03,"providers":[{"billed_charge":72190.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":378.64,"providers":[{"billed_charge":4576.00,"npi":[1396194197]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2166.38,"providers":[{"billed_charge":21409.00,"npi":[1245335629]}]},{"allowed_amount":822.36,"providers":[{"billed_charge":14736.00,"npi":[1215042114]}]},{"allowed_amount":836.38,"providers":[{"billed_charge":14010.00,"npi":[1508971441]}]}]}]},{"name":"LAB/IMMUNOLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"302","description":"LABORATORY - IMMUNOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":238.78,"providers":[{"billed_charge":2949.00,"npi":[1962579029]}]}]}]},{"name":"LAB/HEMATOLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"305","description":"LABORATORY - HEMATOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":128.56,"providers":[{"billed_charge":470.75,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":327.51,"providers":[{"billed_charge":858.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":557.20,"providers":[{"billed_charge":2420.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1536.10,"providers":[{"billed_charge":64291.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2796.77,"providers":[{"billed_charge":6213.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"250965588"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":83.26,"providers":[{"billed_charge":559.00,"npi":[1871594127]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":300.53,"providers":[{"billed_charge":2052.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":464.44,"providers":[{"billed_charge":10236.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":501.03,"providers":[{"billed_charge":2853.00,"npi":[1245335629]}]},{"allowed_amount":141.84,"providers":[{"billed_charge":1010.00,"npi":[1215042114]}]},{"allowed_amount":241.81,"providers":[{"billed_charge":1931.00,"npi":[1508971441]}]}]}]},{"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":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":39.17,"providers":[{"billed_charge":212.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":486.20,"providers":[{"billed_charge":18942.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":456.98,"providers":[{"billed_charge":1268.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1047.85,"providers":[{"billed_charge":1960.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":56.46,"providers":[{"billed_charge":1208.00,"npi":[1245335629]}]}]}]},{"name":"LAB/UROLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"307","description":"LABORATORY - UROLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":516.00,"providers":[{"billed_charge":866.00,"npi":[1699734665]}]}]}]},{"name":"DX X-RAY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"320","description":"RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":501.07,"providers":[{"billed_charge":3970.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":587.42,"providers":[{"billed_charge":3846.00,"npi":[1962579029]}]},{"allowed_amount":4169.11,"providers":[{"billed_charge":65559.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3120.76,"providers":[{"billed_charge":10043.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2102.97,"providers":[{"billed_charge":36058.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":969.12,"providers":[{"billed_charge":10349.00,"npi":[1245335629]}]},{"allowed_amount":939.07,"providers":[{"billed_charge":2365.00,"npi":[1508971441]}]}]}]},{"name":"DX X-RAY/CHEST","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"324","description":"RADIOLOGY - DIAGNOSTIC - CHEST X-RAY","allowed_amounts":[{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4088.39,"providers":[{"billed_charge":15840.00,"npi":[1699734665]}]}]}]},{"name":"CT SCAN","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"350","description":"CT SCAN - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3602.50,"providers":[{"billed_charge":23383.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":9516.82,"providers":[{"billed_charge":164586.00,"npi":[1962579029]}]},{"allowed_amount":109.89,"providers":[{"billed_charge":7226.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4345.28,"providers":[{"billed_charge":12816.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2970.00,"providers":[{"billed_charge":17608.00,"npi":[1245335629]}]},{"allowed_amount":1682.97,"providers":[{"billed_charge":13935.00,"npi":[1508971441]}]}]}]},{"name":"CT SCAN/HEAD","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"351","description":"CT SCAN - HEAD SCAN","allowed_amounts":[{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2052.64,"providers":[{"billed_charge":2660.00,"npi":[1699734665]}]}]}]},{"name":"CT SCAN/BODY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"352","description":"CT SCAN - BODY SCAN","allowed_amounts":[{"tin":{"type":"ein","value":"231352213"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":683.00,"providers":[{"billed_charge":10584.00,"npi":[1548293954]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":17439.07,"providers":[{"billed_charge":37175.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":657.73,"providers":[{"billed_charge":20739.00,"npi":[1396194197]}]}]}]},{"name":"ROUTINE VENIPUNCTURE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"36415","description":"COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE","allowed_amounts":[{"tin":{"type":"ein","value":"842407118"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":154.78,"providers":[{"billed_charge":510.00,"npi":[1073781621]}]}]}]},{"name":"BLOOD/STOR-PROC","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"390","description":"BLOOD STORAGE AND PROCESSING - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":183.98,"providers":[{"billed_charge":1792.00,"npi":[1962579029]}]}]}]},{"name":"ULTRASOUND","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"402","description":"OTHER IMAGING SERVICES - ULTRASOUND","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":623.74,"providers":[{"billed_charge":13081.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352166"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":7394.18,"providers":[{"billed_charge":47124.36,"npi":[1215921457]}]},{"allowed_amount":1221.70,"providers":[{"billed_charge":2983.42,"npi":[1215921457]}]}]}]},{"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":"231352213"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":21711.88,"providers":[{"billed_charge":85774.00,"npi":[1376339226]}]},{"allowed_amount":26263.27,"providers":[{"billed_charge":153790.00,"npi":[1952399933]}]},{"allowed_amount":8151.90,"providers":[{"billed_charge":41328.00,"npi":[1013933175]}]},{"allowed_amount":33703.92,"providers":[{"billed_charge":151832.00,"npi":[1548293954]}]}]},{"tin":{"type":"ein","value":"231352203"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":5028.15,"providers":[{"billed_charge":53271.00,"npi":[1669405072]}]}]},{"tin":{"type":"ein","value":"231352166"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":11283.69,"providers":[{"billed_charge":30946.19,"npi":[1215921457]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":99098.04,"providers":[{"billed_charge":435447.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"844475996"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":12259.80,"providers":[{"billed_charge":60225.00,"npi":[1073047981]}]}]},{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4697.94,"providers":[{"billed_charge":21623.00,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6772.18,"providers":[{"billed_charge":40905.00,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":15653.62,"providers":[{"billed_charge":73546.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":11322.05,"providers":[{"billed_charge":61815.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":90551.29,"providers":[{"billed_charge":999715.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"250965588"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":10602.11,"providers":[{"billed_charge":17679.00,"npi":[1871594127]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":8166.82,"providers":[{"billed_charge":45218.00,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":12491.77,"providers":[{"billed_charge":60000.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":24861.72,"providers":[{"billed_charge":258039.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":21164.62,"providers":[{"billed_charge":126162.00,"npi":[1396194197]}]}]},{"tin":{"type":"ein","value":"934487584"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":12119.06,"providers":[{"billed_charge":26384.27,"npi":[1699515304]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":16541.62,"providers":[{"billed_charge":54959.00,"npi":[1508971441]}]},{"allowed_amount":15789.06,"providers":[{"billed_charge":71462.00,"npi":[1215042114]}]},{"allowed_amount":25332.53,"providers":[{"billed_charge":97051.00,"npi":[1245335629]}]}]}]},{"name":"RURAL/CLINIC","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"521","description":"FREE-STANDING CLINIC - RURAL HEALTH-CLINIC","allowed_amounts":[{"tin":{"type":"ein","value":"231909490"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":3427.64,"providers":[{"billed_charge":9506.30,"npi":[1770288698]}]},{"allowed_amount":195.76,"providers":[{"billed_charge":1141.00,"npi":[1396440244]}]}]},{"tin":{"type":"ein","value":"232180889"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":395.17,"providers":[{"billed_charge":1197.00,"npi":[1407091077]}]}]},{"tin":{"type":"ein","value":"273795179"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":1566.08,"providers":[{"billed_charge":1560.00,"npi":[1649525569]}]}]}]},{"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":"231352213"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":225.01,"providers":[{"billed_charge":523.08,"npi":[1376339226]}]},{"allowed_amount":339.86,"providers":[{"billed_charge":861.06,"npi":[1952399933]}]},{"allowed_amount":277.91,"providers":[{"billed_charge":558.36,"npi":[1013933175]}]},{"allowed_amount":267.68,"providers":[{"billed_charge":1338.14,"npi":[1548293954]}]}]},{"tin":{"type":"ein","value":"231352203"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":247.41,"providers":[{"billed_charge":477.49,"npi":[1669405072]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":1035.47,"providers":[{"billed_charge":2213.42,"npi":[1699734665]}]},{"allowed_amount":1054.70,"providers":[{"billed_charge":5558.08,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":27.39,"providers":[{"billed_charge":250.34,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"844475996"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":96.48,"providers":[{"billed_charge":337.04,"npi":[1073047981]}]}]},{"tin":{"type":"ein","value":"240795463"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":17.15,"providers":[{"billed_charge":61.50,"npi":[1083614382]}]},{"allowed_amount":47834.05,"providers":[{"billed_charge":329365.48,"npi":[1083614382]}]}]},{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":214.34,"providers":[{"billed_charge":1785.90,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":270.63,"providers":[{"billed_charge":691.03,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":224.06,"providers":[{"billed_charge":3000.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":312.55,"providers":[{"billed_charge":1059.11,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":23040.00,"providers":[{"billed_charge":330096.13,"npi":[1275157455]}]},{"allowed_amount":1193.68,"providers":[{"billed_charge":16878.10,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"250965588"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":38.78,"providers":[{"billed_charge":144.39,"npi":[1871594127]}]},{"allowed_amount":24371.20,"providers":[{"billed_charge":92557.63,"npi":[1871594127]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":571.31,"providers":[{"billed_charge":2296.00,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":1.50,"providers":[{"billed_charge":4499.17,"npi":[1437865953]}]},{"allowed_amount":4918.95,"providers":[{"billed_charge":42736.89,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":13886.32,"providers":[{"billed_charge":15359.75,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":308.33,"providers":[{"billed_charge":1690.33,"npi":[1396194197]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":456.09,"providers":[{"billed_charge":5214.00,"npi":[1508971441]}]},{"allowed_amount":984.77,"providers":[{"billed_charge":7499.00,"npi":[1245335629]}]},{"allowed_amount":32.72,"providers":[{"billed_charge":680.00,"npi":[1215042114]}]}]}]},{"name":"SELF-ADMINISTRABLE DRUGS","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"637","description":"SELF-ADMINISTRABLE DRUGS","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":0.30,"providers":[{"billed_charge":6.39,"npi":[1962579029]}]}]}]},{"name":"EKG/ECG","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"730","description":"EKG/ECG - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"231352213"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":281.83,"providers":[{"billed_charge":822.00,"npi":[1376339226]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2636.54,"providers":[{"billed_charge":48888.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1952.58,"providers":[{"billed_charge":13124.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":257.18,"providers":[{"billed_charge":4572.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":306.01,"providers":[{"billed_charge":1233.00,"npi":[1396194197]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":174.46,"providers":[{"billed_charge":4571.00,"npi":[1245335629]}]}]}]},{"name":"HEMO/COMPOSITE","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"821","description":"HEMODIALYSIS - OUTPT OR HOME - HEMODIALYSIS/COMPOSITE RATE","allowed_amounts":[{"tin":{"type":"ein","value":"851188718"},"service_code":["65"],"billing_class":"institutional","payments":[{"allowed_amount":5250.00,"providers":[{"billed_charge":26250.00,"npi":[1184301269]}]}]}]},{"name":"BH/INTENS OP/CHEM DEP","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"906","description":"INTENSIVE OUTPATIENT SERVICES - CHEMICAL DEPENDENCY","allowed_amounts":[{"tin":{"type":"ein","value":"863916163"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":1046.30,"providers":[{"billed_charge":25000.00,"npi":[1023688157]}]}]},{"tin":{"type":"ein","value":"831651485"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":32250.00,"providers":[{"billed_charge":270255.00,"npi":[1801360573]}]}]}]},{"name":"PSYTX W PT W E/M 30 MIN","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90833","description":"PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE","allowed_amounts":[{"tin":{"type":"ein","value":"263447487"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":509.49,"providers":[{"billed_charge":1395.00,"npi":[1740994599]}]}]},{"tin":{"type":"ein","value":"465013529"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":293.91,"providers":[{"billed_charge":470.00,"npi":[1699817353]}]},{"allowed_amount":2838.22,"providers":[{"billed_charge":5170.00,"npi":[1740775444]}]},{"allowed_amount":535.40,"providers":[{"billed_charge":846.00,"npi":[1740775444]}]}]}]},{"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":"464461587"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":179.96,"providers":[{"billed_charge":350.00,"npi":[1487306916]}]}]},{"tin":{"type":"ein","value":"208786845"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":2226.91,"providers":[{"billed_charge":2630.00,"npi":[1053452755]}]}]},{"tin":{"type":"ein","value":"811894745"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":1381.38,"providers":[{"billed_charge":2250.00,"npi":[1073987186]}]}]},{"tin":{"type":"ein","value":"332897648"},"service_code":["11","02"],"billing_class":"professional","payments":[{"allowed_amount":113.70,"providers":[{"billed_charge":130.00,"npi":[1124870555]}]},{"allowed_amount":100.91,"providers":[{"billed_charge":130.00,"npi":[1124870555]}]}]},{"tin":{"type":"ein","value":"871904636"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":414.06,"providers":[{"billed_charge":600.00,"npi":[1194140848]}]}]},{"tin":{"type":"ein","value":"263447487"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":1557.53,"providers":[{"billed_charge":3750.00,"npi":[1396629556]}]},{"allowed_amount":3673.70,"providers":[{"billed_charge":7500.00,"npi":[1982384970]}]},{"allowed_amount":2743.63,"providers":[{"billed_charge":5500.00,"npi":[1396629556]}]},{"allowed_amount":239.08,"providers":[{"billed_charge":500.00,"npi":[1689209470]}]},{"allowed_amount":9237.07,"providers":[{"billed_charge":22250.00,"npi":[1295598746]}]},{"allowed_amount":2283.97,"providers":[{"billed_charge":5500.00,"npi":[1982384970]}]},{"allowed_amount":201.82,"providers":[{"billed_charge":500.00,"npi":[1689209470]}]}]},{"tin":{"type":"ein","value":"832507546"},"service_code":["02","10"],"billing_class":"professional","payments":[{"allowed_amount":1388.61,"providers":[{"billed_charge":3159.00,"npi":[1831513886]}]},{"allowed_amount":1234.32,"providers":[{"billed_charge":2808.00,"npi":[1306533005]}]},{"allowed_amount":1464.87,"providers":[{"billed_charge":3159.00,"npi":[1306533005]}]},{"allowed_amount":308.58,"providers":[{"billed_charge":702.00,"npi":[1205675550,1497301907]}]},{"allowed_amount":475.58,"providers":[{"billed_charge":1053.00,"npi":[1497301907]}]},{"allowed_amount":154.29,"providers":[{"billed_charge":351.00,"npi":[1356838395,1487280665]}]},{"allowed_amount":617.16,"providers":[{"billed_charge":1404.00,"npi":[1881686012]}]},{"allowed_amount":655.29,"providers":[{"billed_charge":1404.00,"npi":[1356838395]}]},{"allowed_amount":501.00,"providers":[{"billed_charge":1053.00,"npi":[1487280665]}]},{"allowed_amount":2466.87,"providers":[{"billed_charge":5265.00,"npi":[1831513886]}]},{"allowed_amount":167.00,"providers":[{"billed_charge":351.00,"npi":[1205675550,1881686012,1821799214]}]}]},{"tin":{"type":"ein","value":"270555071"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":622.13,"providers":[{"billed_charge":1080.00,"npi":[1427881689]}]},{"allowed_amount":271.62,"providers":[{"billed_charge":540.00,"npi":[1427881689]}]}]},{"tin":{"type":"ein","value":"841843249"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":247.83,"providers":[{"billed_charge":320.00,"npi":[1841913332]}]}]}]},{"name":"PSTAY/PARTIAL HOSP","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"912","description":"PSYCHIATRIC/PSYCHOLOGICAL SERVICES - PARTIAL HOSPITALIZATION","allowed_amounts":[{"tin":{"type":"ein","value":"863916163"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":2317.95,"providers":[{"billed_charge":31500.00,"npi":[1023688157]}]}]},{"tin":{"type":"ein","value":"831651485"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":22050.00,"providers":[{"billed_charge":100590.00,"npi":[1801360573]}]}]}]},{"name":"PSYCHIATRIC CARE INTENSIVE 4","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"913","description":"PSYCHIATRIC CARE INTENSIVE 4-6 HOURS","allowed_amounts":[{"tin":{"type":"ein","value":"931373954"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":237.95,"providers":[{"billed_charge":26100.00,"npi":[1508549155]}]}]}]},{"name":"ELECTROCARDIOGRAM, COMPLETE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"93000","description":"ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT","allowed_amounts":[{"tin":{"type":"ein","value":"842407118"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":72.85,"providers":[{"billed_charge":250.00,"npi":[1073781621]}]}]}]},{"name":"OTHER RX SVS","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"940","description":"OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":937.37,"providers":[{"billed_charge":17803.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":681.73,"providers":[{"billed_charge":14757.00,"npi":[1699734665]}]}]}]},{"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":"842407118"},"service_code":["11","20"],"billing_class":"professional","payments":[{"allowed_amount":21935.40,"providers":[{"billed_charge":28320.00,"npi":[1073781621]}]},{"allowed_amount":92.85,"providers":[{"billed_charge":120.00,"npi":[1073781621]}]}]}]},{"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":"842407118"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":9404.64,"providers":[{"billed_charge":21600.00,"npi":[1073781621]}]}]},{"tin":{"type":"ein","value":"263447487"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":803.37,"providers":[{"billed_charge":1850.00,"npi":[1740994599]}]}]},{"tin":{"type":"ein","value":"465013529"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":893.72,"providers":[{"billed_charge":1782.00,"npi":[1740775444]}]},{"allowed_amount":3393.20,"providers":[{"billed_charge":9504.00,"npi":[1740775444]}]}]}]},{"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":"232840702"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":6.45,"providers":[{"billed_charge":6.45,"npi":[1003819103]}]}]},{"tin":{"type":"ein","value":"232742438"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":923.29,"providers":[{"billed_charge":1905.00,"npi":[1548247455]}]}]},{"tin":{"type":"ein","value":"822687236"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":268.99,"providers":[{"billed_charge":922.50,"npi":[1811552136]}]}]},{"tin":{"type":"ein","value":"236001907"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":676.11,"providers":[{"billed_charge":1488.00,"npi":[1982601894]}]}]},{"tin":{"type":"ein","value":"237239334"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":581.60,"providers":[{"billed_charge":5115.50,"npi":[1194798082]}]}]}]},{"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":"236001907"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":3265.36,"providers":[{"billed_charge":9440.00,"npi":[1982601894]}]}]}]},{"name":"AMB SERVICE BLS NONEMERG TRA","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A0428","description":"AMBULANCE SERVICE, BASIC LIFE SUPPORT, NONEMERGENCY TRANSPORT, (BLS)","allowed_amounts":[{"tin":{"type":"ein","value":"232742438"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1074.15,"providers":[{"billed_charge":4500.00,"npi":[1548247455]}]}]}]},{"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":"236001907"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":687.44,"providers":[{"billed_charge":1730.00,"npi":[1982601894]}]}]}]}]}