{
    "reporting_entity_name": "Centene Management Company LLC",
    "reporting_entity_type": "Third Party Administrator",
    "version": "2.0.0",
    "last_updated_on": "2026-07-29",
    "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": 593.46,
                            "providers": [{
                                    "billed_charge": 1978.05,
                                    "npi": [1083708226]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "470484764"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 2.63,
                            "providers": [{
                                    "billed_charge": 8.75,
                                    "npi": [1265517759]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "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": 5901.30,
                            "providers": [{
                                    "billed_charge": 12448.60,
                                    "npi": [1083708226]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "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": 118.70,
                            "providers": [{
                                    "billed_charge": 234.00,
                                    "npi": [1265402390]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "420504780"
                    },
                    "service_code": ["22", "23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 1179.51,
                            "providers": [{
                                    "billed_charge": 2004.25,
                                    "npi": [1083708226]
                                }
                            ]
                        }, {
                            "allowed_amount": 7.33,
                            "providers": [{
                                    "billed_charge": 70.54,
                                    "npi": [1083708226]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "421019872"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 120.22,
                            "providers": [{
                                    "billed_charge": 142.84,
                                    "npi": [1962594622]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "426004813"
                    },
                    "service_code": ["22", "23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 9968.87,
                            "providers": [{
                                    "billed_charge": 30476.00,
                                    "npi": [1376544320]
                                }
                            ]
                        }, {
                            "allowed_amount": 2646.31,
                            "providers": [{
                                    "billed_charge": 9030.00,
                                    "npi": [1699541870]
                                }
                            ]
                        }, {
                            "allowed_amount": 4253.38,
                            "providers": [{
                                    "billed_charge": 8793.00,
                                    "npi": [1376544320]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "470484764"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 3654.32,
                            "providers": [{
                                    "billed_charge": 22269.00,
                                    "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": 4632.99,
                            "providers": [{
                                    "billed_charge": 8719.55,
                                    "npi": [1083708226]
                                }
                            ]
                        }, {
                            "allowed_amount": 59.14,
                            "providers": [{
                                    "billed_charge": 320.50,
                                    "npi": [1083708226]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "421019872"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 570.81,
                            "providers": [{
                                    "billed_charge": 800.82,
                                    "npi": [1962594622]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "420680452"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 1580.74,
                            "providers": [{
                                    "billed_charge": 1902.47,
                                    "npi": [1396837951]
                                }
                            ]
                        }, {
                            "allowed_amount": 127.66,
                            "providers": [{
                                    "billed_charge": 127.66,
                                    "npi": [1356433049]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "420680354"
                    },
                    "service_code": ["22"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 787.80,
                            "providers": [{
                                    "billed_charge": 2625.38,
                                    "npi": [1942392600]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "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": 889.41,
                            "providers": [{
                                    "billed_charge": 1614.19,
                                    "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": 322.31,
                            "providers": [{
                                    "billed_charge": 698.86,
                                    "npi": [1083708226]
                                }
                            ]
                        }, {
                            "allowed_amount": 4.27,
                            "providers": [{
                                    "billed_charge": 48.22,
                                    "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": 37.88,
                            "providers": [{
                                    "billed_charge": 96.42,
                                    "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": 27571.51,
                            "providers": [{
                                    "billed_charge": 56045.73,
                                    "npi": [1083708226]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "470484764"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 13841.02,
                            "providers": [{
                                    "billed_charge": 32733.00,
                                    "npi": [1265517759]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "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": 2299.35,
                            "providers": [{
                                    "billed_charge": 7664.15,
                                    "npi": [1083708226]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "420680452"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 383.72,
                            "providers": [{
                                    "billed_charge": 1278.95,
                                    "npi": [1396837951]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "426004813"
                    },
                    "service_code": ["22", "23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 2.02,
                            "providers": [{
                                    "billed_charge": 2572.15,
                                    "npi": [1376544320]
                                }
                            ]
                        }, {
                            "allowed_amount": 1571.76,
                            "providers": [{
                                    "billed_charge": 5239.21,
                                    "npi": [1376544320]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "470484764"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 1311.72,
                            "providers": [{
                                    "billed_charge": 4372.20,
                                    "npi": [1265517759]
                                }
                            ]
                        }
                    ]
                }, {
                    "tin": {
                        "type": "ein",
                        "value": "420680354"
                    },
                    "service_code": ["23"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 1.63,
                            "providers": [{
                                    "billed_charge": 1912.80,
                                    "npi": [1942392600]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "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": ["11", "22"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 297.08,
                            "providers": [{
                                    "billed_charge": 1114.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }, {
                            "allowed_amount": 76.66,
                            "providers": [{
                                    "billed_charge": 270.00,
                                    "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": ["11", "22"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 93.41,
                            "providers": [{
                                    "billed_charge": 322.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }, {
                            "allowed_amount": 402.00,
                            "providers": [{
                                    "billed_charge": 1740.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "GUIDANCE FOR RADIAJ TX DLVR",
            "billing_code_type": "CPT",
            "billing_code_type_version": "2022",
            "billing_code": "77387",
            "description": "GUIDANCE FOR LOCALIZATION OF TARGET VOLUME FOR DELIVERY OF RADIATION TREATMENT DELIVERY, INCLUDES IN",
            "allowed_amounts": [{
                    "tin": {
                        "type": "ein",
                        "value": "999999999"
                    },
                    "service_code": ["22", "21"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 27.78,
                            "providers": [{
                                    "billed_charge": 176.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "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": 272.07,
                            "providers": [{
                                    "billed_charge": 2363.40,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "GROUP PSYCHOTHERAPY",
            "billing_code_type": "CPT",
            "billing_code_type_version": "2022",
            "billing_code": "90853",
            "description": "GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP)",
            "allowed_amounts": [{
                    "tin": {
                        "type": "ein",
                        "value": "010772181"
                    },
                    "service_code": ["11"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 66.48,
                            "providers": [{
                                    "billed_charge": 195.00,
                                    "npi": [1609539550]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "PSTAY/INDIV RX",
            "billing_code_type": "RC",
            "billing_code_type_version": "2022",
            "billing_code": "914",
            "description": "PSYCHIATRIC/PSYCHOLOGICAL SERVICES - INDIVIDUAL THERAPY",
            "allowed_amounts": [{
                    "tin": {
                        "type": "ein",
                        "value": "420859940"
                    },
                    "service_code": ["22"],
                    "billing_class": "institutional",
                    "payments": [{
                            "allowed_amount": 297.45,
                            "providers": [{
                                    "billed_charge": 612.00,
                                    "npi": [1730253360]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "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": 11.95,
                            "providers": [{
                                    "billed_charge": 25.00,
                                    "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": 1808.90,
                            "providers": [{
                                    "billed_charge": 7166.00,
                                    "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": 730.90,
                            "providers": [{
                                    "billed_charge": 2603.00,
                                    "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": 1199.94,
                            "providers": [{
                                    "billed_charge": 4780.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "ADAPTIVE BEHAVIOR TX BY TECH",
            "billing_code_type": "CPT",
            "billing_code_type_version": "2022",
            "billing_code": "97153",
            "description": "ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN",
            "allowed_amounts": [{
                    "tin": {
                        "type": "ein",
                        "value": "421388270"
                    },
                    "service_code": ["11"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 13713.48,
                            "providers": [{
                                    "billed_charge": 13829.40,
                                    "npi": [1912728692]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "ADAPT BEHAVIOR TX PHYS/QHP",
            "billing_code_type": "CPT",
            "billing_code_type_version": "2022",
            "billing_code": "97155",
            "description": "ADAPT BHV TX PRTCL MODIFICAJ PHYS/QHP EA 15 MIN",
            "allowed_amounts": [{
                    "tin": {
                        "type": "ein",
                        "value": "421388270"
                    },
                    "service_code": ["11"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 545.04,
                            "providers": [{
                                    "billed_charge": 1304.16,
                                    "npi": [1912728692]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "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": 1549.17,
                            "providers": [{
                                    "billed_charge": 4654.00,
                                    "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": 1330.66,
                            "providers": [{
                                    "billed_charge": 3092.00,
                                    "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": "999999999"
                    },
                    "service_code": ["11"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 16481.96,
                            "providers": [{
                                    "billed_charge": 26127.47,
                                    "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": 1003.86,
                            "providers": [{
                                    "billed_charge": 1331.00,
                                    "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": 894.60,
                            "providers": [{
                                    "billed_charge": 1584.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "OFFICE/OUTPATIENT VISIT NEW",
            "billing_code_type": "CPT",
            "billing_code_type_version": "2022",
            "billing_code": "99204",
            "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": 777.91,
                            "providers": [{
                                    "billed_charge": 1649.00,
                                    "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": ["11"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 1945.25,
                            "providers": [{
                                    "billed_charge": 5747.98,
                                    "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": ["22", "11", "10"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 100.44,
                            "providers": [{
                                    "billed_charge": 155.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }, {
                            "allowed_amount": 108.04,
                            "providers": [{
                                    "billed_charge": 150.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }, {
                            "allowed_amount": 4152.22,
                            "providers": [{
                                    "billed_charge": 8639.06,
                                    "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", "51", "21"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 1539.16,
                            "providers": [{
                                    "billed_charge": 8848.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }, {
                            "allowed_amount": 133.84,
                            "providers": [{
                                    "billed_charge": 1000.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }, {
                            "allowed_amount": 341.28,
                            "providers": [{
                                    "billed_charge": 1200.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "SUBSEQUENT HOSPITAL CARE",
            "billing_code_type": "CPT",
            "billing_code_type_version": "2022",
            "billing_code": "99233",
            "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", "21"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 1202.77,
                            "providers": [{
                                    "billed_charge": 8616.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }, {
                            "allowed_amount": 101.50,
                            "providers": [{
                                    "billed_charge": 718.00,
                                    "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": 5594.51,
                            "providers": [{
                                    "billed_charge": 48259.00,
                                    "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": 10073.08,
                            "providers": [{
                                    "billed_charge": 91328.00,
                                    "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": 5052.15,
                            "providers": [{
                                    "billed_charge": 10756.64,
                                    "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": 7286.69,
                            "providers": [{
                                    "billed_charge": 14172.10,
                                    "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": 1310.31,
                            "providers": [{
                                    "billed_charge": 2642.74,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "FLTR DISPBL W/POS ARWAY PRSS",
            "billing_code_type": "HCPCS",
            "billing_code_type_version": "2022",
            "billing_code": "A7038",
            "description": "FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE",
            "allowed_amounts": [{
                    "tin": {
                        "type": "ein",
                        "value": "999999999"
                    },
                    "service_code": ["12"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 17.69,
                            "providers": [{
                                    "billed_charge": 23.00,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }, {
            "name": "CONTINUOUS POS AIRWAY PRESSU",
            "billing_code_type": "HCPCS",
            "billing_code_type_version": "2022",
            "billing_code": "E0601",
            "description": "CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE",
            "allowed_amounts": [{
                    "tin": {
                        "type": "ein",
                        "value": "999999999"
                    },
                    "service_code": ["12"],
                    "billing_class": "professional",
                    "payments": [{
                            "allowed_amount": 439.31,
                            "providers": [{
                                    "billed_charge": 4710.16,
                                    "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": 10713.60,
                            "providers": [{
                                    "billed_charge": 31521.60,
                                    "npi": [1234567893]
                                }
                            ]
                        }
                    ]
                }
            ]
        }
    ]
}
