{"reporting_entity_name":"Centene Management Company LLC","reporting_entity_type":"Third Party Administrator","version":"2.0.0","last_updated_on":"2026-07-28","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":"474442902"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1.08,"providers":[{"billed_charge":2.00,"npi":[1346607017]}]}]},{"tin":{"type":"ein","value":"340733166"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":22.02,"providers":[{"billed_charge":273.25,"npi":[1083696710]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":363.96,"providers":[{"billed_charge":1775.75,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"340714357"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":21.75,"providers":[{"billed_charge":148.01,"npi":[1861506560]}]}]},{"tin":{"type":"ein","value":"340714456"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7.66,"providers":[{"billed_charge":22.40,"npi":[1790837235]}]}]},{"tin":{"type":"ein","value":"340714684"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3.35,"providers":[{"billed_charge":6.20,"npi":[1194763045]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":92.48,"providers":[{"billed_charge":620.05,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"311480941"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2.32,"providers":[{"billed_charge":3.81,"npi":[1598868655]}]}]},{"tin":{"type":"ein","value":"344429514"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":17.76,"providers":[{"billed_charge":266.25,"npi":[1942267760]}]}]},{"tin":{"type":"ein","value":"384105653"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7.94,"providers":[{"billed_charge":800.70,"npi":[1326020447]}]}]},{"tin":{"type":"ein","value":"314379436"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":13.67,"providers":[{"billed_charge":25.10,"npi":[1235174327]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":39.03,"providers":[{"billed_charge":292.20,"npi":[1972535052]}]},{"allowed_amount":778.09,"providers":[{"billed_charge":6829.15,"npi":[1255377149]}]},{"allowed_amount":246.91,"providers":[{"billed_charge":737.00,"npi":[1801937008]}]},{"allowed_amount":25.95,"providers":[{"billed_charge":190.30,"npi":[1467484972]}]}]},{"tin":{"type":"ein","value":"340714618"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":11.82,"providers":[{"billed_charge":66.45,"npi":[1215989611]}]}]},{"tin":{"type":"ein","value":"311439334"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":12.01,"providers":[{"billed_charge":18.35,"npi":[1417037045]}]}]}]},{"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":"340733166"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":206.58,"providers":[{"billed_charge":2908.00,"npi":[1083696710]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":11505.93,"providers":[{"billed_charge":57226.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3396.41,"providers":[{"billed_charge":27860.00,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"340714771"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":432.04,"providers":[{"billed_charge":3816.00,"npi":[1871606921]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7241.04,"providers":[{"billed_charge":21720.00,"npi":[1255377149]}]},{"allowed_amount":1330.03,"providers":[{"billed_charge":5572.00,"npi":[1801937008]}]}]},{"tin":{"type":"ein","value":"311439334"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1814.36,"providers":[{"billed_charge":10438.00,"npi":[1417037045]}]}]}]},{"name":"STERILE SUPPLY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"272","description":"MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY","allowed_amounts":[{"tin":{"type":"ein","value":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":163.35,"providers":[{"billed_charge":361.30,"npi":[1073688354]}]}]}]},{"name":"LABORATORY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"300","description":"LABORATORY - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"341883132"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":433.93,"providers":[{"billed_charge":5344.00,"npi":[1598765539]}]},{"allowed_amount":1242.80,"providers":[{"billed_charge":10529.00,"npi":[1598765539]}]}]},{"tin":{"type":"ein","value":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":481.98,"providers":[{"billed_charge":5675.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"340733166"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":128.89,"providers":[{"billed_charge":560.00,"npi":[1083696710]}]},{"allowed_amount":35.71,"providers":[{"billed_charge":63.00,"npi":[1083696710]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":142.79,"providers":[{"billed_charge":252.00,"npi":[1821035940]}]},{"allowed_amount":1141.87,"providers":[{"billed_charge":5026.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":129.24,"providers":[{"billed_charge":286.00,"npi":[1679525919]}]},{"allowed_amount":161.92,"providers":[{"billed_charge":1512.00,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"311480941"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6.02,"providers":[{"billed_charge":37.66,"npi":[1598868655]}]}]},{"tin":{"type":"ein","value":"310833936"},"service_code":["23","19"],"billing_class":"institutional","payments":[{"allowed_amount":56.26,"providers":[{"billed_charge":239.00,"npi":[1548212988]}]},{"allowed_amount":396.20,"providers":[{"billed_charge":2208.00,"npi":[1548212988]}]}]},{"tin":{"type":"ein","value":"311079309"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7.21,"providers":[{"billed_charge":23.00,"npi":[1700950060]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":72.08,"providers":[{"billed_charge":366.00,"npi":[1255377149]}]},{"allowed_amount":129.93,"providers":[{"billed_charge":377.00,"npi":[1467484972]}]},{"allowed_amount":25.38,"providers":[{"billed_charge":153.00,"npi":[1801937008]}]}]},{"tin":{"type":"ein","value":"311439334"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":19.47,"providers":[{"billed_charge":87.00,"npi":[1982784534]}]},{"allowed_amount":126.45,"providers":[{"billed_charge":606.00,"npi":[1417037045]}]}]}]},{"name":"LAB/CHEMISTRY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"301","description":"LABORATORY - CHEMISTRY","allowed_amounts":[{"tin":{"type":"ein","value":"341883132"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":1904.37,"providers":[{"billed_charge":22298.00,"npi":[1598765539]}]},{"allowed_amount":22.09,"providers":[{"billed_charge":6122.00,"npi":[1598765539]}]}]},{"tin":{"type":"ein","value":"340714357"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":20.39,"providers":[{"billed_charge":171.00,"npi":[1861506560]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":7929.82,"providers":[{"billed_charge":17521.00,"npi":[1821035940]}]},{"allowed_amount":1989.37,"providers":[{"billed_charge":3512.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"340714456"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":395.14,"providers":[{"billed_charge":711.00,"npi":[1790837235]}]}]},{"tin":{"type":"ein","value":"340714771"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":734.44,"providers":[{"billed_charge":1237.00,"npi":[1871606921]}]}]},{"tin":{"type":"ein","value":"344429514"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1410.38,"providers":[{"billed_charge":2688.00,"npi":[1942267760]}]}]},{"tin":{"type":"ein","value":"310833936"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":40.14,"providers":[{"billed_charge":157.00,"npi":[1548212988]}]}]},{"tin":{"type":"ein","value":"340714593"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":109.47,"providers":[{"billed_charge":179.00,"npi":[1598719346]}]}]},{"tin":{"type":"ein","value":"314446959"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":839.09,"providers":[{"billed_charge":1009.00,"npi":[1710913462]}]}]},{"tin":{"type":"ein","value":"384105653"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1137.98,"providers":[{"billed_charge":1873.00,"npi":[1326020447]}]}]},{"tin":{"type":"ein","value":"311070877"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":314.42,"providers":[{"billed_charge":599.00,"npi":[1215935366]}]}]},{"tin":{"type":"ein","value":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4869.37,"providers":[{"billed_charge":11980.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"342032340"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":362.73,"providers":[{"billed_charge":1234.00,"npi":[1225361181]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":245.79,"providers":[{"billed_charge":3663.00,"npi":[1234567893]}]}]},{"tin":{"type":"ein","value":"340714618"},"service_code":["23","21"],"billing_class":"institutional","payments":[{"allowed_amount":855.10,"providers":[{"billed_charge":2178.00,"npi":[1215989611]}]},{"allowed_amount":3012.51,"providers":[{"billed_charge":8993.00,"npi":[1215989611]}]}]},{"tin":{"type":"ein","value":"340733166"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":2409.39,"providers":[{"billed_charge":4672.00,"npi":[1083696710]}]},{"allowed_amount":19.84,"providers":[{"billed_charge":35.00,"npi":[1083696710]}]}]},{"tin":{"type":"ein","value":"621757929"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1096.78,"providers":[{"billed_charge":3304.62,"npi":[1881785863]}]}]},{"tin":{"type":"ein","value":"311724085"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2608.90,"providers":[{"billed_charge":4815.00,"npi":[1669410940]}]}]},{"tin":{"type":"ein","value":"340714684"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":639.22,"providers":[{"billed_charge":1474.00,"npi":[1194763045]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":902.59,"providers":[{"billed_charge":2126.00,"npi":[1679525919]}]},{"allowed_amount":5337.48,"providers":[{"billed_charge":11268.00,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"311480941"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":459.49,"providers":[{"billed_charge":1698.50,"npi":[1598868655]}]},{"allowed_amount":1047.58,"providers":[{"billed_charge":8960.31,"npi":[1598868655]}]}]},{"tin":{"type":"ein","value":"311079309"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":959.27,"providers":[{"billed_charge":3570.00,"npi":[1700950060]}]}]},{"tin":{"type":"ein","value":"314379509"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":361.58,"providers":[{"billed_charge":1079.85,"npi":[1215936927]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4287.11,"providers":[{"billed_charge":10790.00,"npi":[1801937008]}]},{"allowed_amount":5907.60,"providers":[{"billed_charge":12335.00,"npi":[1255377149]}]},{"allowed_amount":1537.97,"providers":[{"billed_charge":2976.00,"npi":[1467484972]}]},{"allowed_amount":445.39,"providers":[{"billed_charge":1156.00,"npi":[1972535052]}]}]},{"tin":{"type":"ein","value":"311439334"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2594.61,"providers":[{"billed_charge":8260.00,"npi":[1417037045]}]},{"allowed_amount":51.81,"providers":[{"billed_charge":95.00,"npi":[1710067376]}]},{"allowed_amount":738.82,"providers":[{"billed_charge":1995.00,"npi":[1982784534]}]}]}]},{"name":"LAB/IMMUNOLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"302","description":"LABORATORY - IMMUNOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"340714585"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":3892.70,"providers":[{"billed_charge":6874.00,"npi":[1679525919]}]},{"allowed_amount":222.52,"providers":[{"billed_charge":357.00,"npi":[1679525919]}]}]}]},{"name":"LAB/HEMATOLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"305","description":"LABORATORY - HEMATOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"341883132"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":101.92,"providers":[{"billed_charge":1650.00,"npi":[1598765539]}]}]},{"tin":{"type":"ein","value":"340733166"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":342.33,"providers":[{"billed_charge":592.00,"npi":[1083696710]}]}]},{"tin":{"type":"ein","value":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1401.63,"providers":[{"billed_charge":4872.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":108.84,"providers":[{"billed_charge":192.00,"npi":[1821035940]}]},{"allowed_amount":1869.70,"providers":[{"billed_charge":3777.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"311724085"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":567.96,"providers":[{"billed_charge":997.00,"npi":[1669410940]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":643.15,"providers":[{"billed_charge":1184.00,"npi":[1679525919]}]},{"allowed_amount":64.85,"providers":[{"billed_charge":192.00,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"311480941"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":130.25,"providers":[{"billed_charge":1394.46,"npi":[1598868655]}]},{"allowed_amount":22.01,"providers":[{"billed_charge":60.28,"npi":[1598868655]}]}]},{"tin":{"type":"ein","value":"311079309"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":57.98,"providers":[{"billed_charge":216.00,"npi":[1700950060]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":211.36,"providers":[{"billed_charge":252.00,"npi":[1467484972]}]},{"allowed_amount":1455.95,"providers":[{"billed_charge":2844.00,"npi":[1255377149]}]},{"allowed_amount":600.37,"providers":[{"billed_charge":960.00,"npi":[1801937008]}]}]},{"tin":{"type":"ein","value":"311439334"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":409.79,"providers":[{"billed_charge":853.00,"npi":[1417037045]}]}]},{"tin":{"type":"ein","value":"384105653"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":92.25,"providers":[{"billed_charge":194.00,"npi":[1326020447]}]}]}]},{"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":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1587.51,"providers":[{"billed_charge":5747.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4996.05,"providers":[{"billed_charge":19913.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":462.25,"providers":[{"billed_charge":2007.00,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"311480941"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":35.09,"providers":[{"billed_charge":96.13,"npi":[1598868655]}]}]},{"tin":{"type":"ein","value":"310833936"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":921.34,"providers":[{"billed_charge":1789.00,"npi":[1548212988]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1626.28,"providers":[{"billed_charge":3998.00,"npi":[1255377149]}]}]},{"tin":{"type":"ein","value":"311439334"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":18.96,"providers":[{"billed_charge":80.00,"npi":[1417037045]}]}]}]},{"name":"LAB/UROLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"307","description":"LABORATORY - UROLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":369.72,"providers":[{"billed_charge":637.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":12.47,"providers":[{"billed_charge":22.00,"npi":[1821035940]}]},{"allowed_amount":548.48,"providers":[{"billed_charge":941.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":9.06,"providers":[{"billed_charge":16.00,"npi":[1679525919]}]},{"allowed_amount":8.61,"providers":[{"billed_charge":22.00,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":141.10,"providers":[{"billed_charge":332.00,"npi":[1255377149]}]}]}]},{"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":"341883132"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":136.83,"providers":[{"billed_charge":678.00,"npi":[1598765539]}]},{"allowed_amount":140.18,"providers":[{"billed_charge":1614.00,"npi":[1598765539]}]}]},{"tin":{"type":"ein","value":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":257.01,"providers":[{"billed_charge":1280.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1157.60,"providers":[{"billed_charge":6940.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"310833936"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1263.35,"providers":[{"billed_charge":2747.00,"npi":[1548212988]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1183.64,"providers":[{"billed_charge":2870.00,"npi":[1255377149]}]}]}]},{"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":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":530.03,"providers":[{"billed_charge":1530.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1623.00,"providers":[{"billed_charge":6080.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":176.86,"providers":[{"billed_charge":526.00,"npi":[1255377149]}]}]}]},{"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":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1876.32,"providers":[{"billed_charge":6636.00,"npi":[1255377149]}]}]}]},{"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":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2372.52,"providers":[{"billed_charge":9281.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":14644.43,"providers":[{"billed_charge":37322.00,"npi":[1821035940]}]},{"allowed_amount":416.10,"providers":[{"billed_charge":734.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1324.55,"providers":[{"billed_charge":3692.00,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":8415.11,"providers":[{"billed_charge":31837.00,"npi":[1255377149]}]}]}]},{"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":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":1007.16,"providers":[{"billed_charge":2099.79,"npi":[1811154388]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":161.40,"providers":[{"billed_charge":652.80,"npi":[1234567893]}]}]}]},{"name":"PHYS THERP/VISIT","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"421","description":"PHYSICAL THERAPY/VISIT","allowed_amounts":[{"tin":{"type":"ein","value":"341883132"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":414.07,"providers":[{"billed_charge":2302.00,"npi":[1598765539]}]}]}]},{"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":"341883132"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":5314.63,"providers":[{"billed_charge":8081.00,"npi":[1598765539]}]}]},{"tin":{"type":"ein","value":"340733166"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":9641.89,"providers":[{"billed_charge":56795.00,"npi":[1083696710]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":75860.75,"providers":[{"billed_charge":406906.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"340714357"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7866.30,"providers":[{"billed_charge":35357.00,"npi":[1861506560]}]}]},{"tin":{"type":"ein","value":"340714456"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1437.09,"providers":[{"billed_charge":5068.00,"npi":[1790837235]}]}]},{"tin":{"type":"ein","value":"311724085"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":5191.12,"providers":[{"billed_charge":6799.00,"npi":[1669410940]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":18871.44,"providers":[{"billed_charge":113669.00,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"311480941"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":678.89,"providers":[{"billed_charge":3997.57,"npi":[1598868655]}]}]},{"tin":{"type":"ein","value":"310833936"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":24690.60,"providers":[{"billed_charge":78401.00,"npi":[1548212988]}]}]},{"tin":{"type":"ein","value":"311079309"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":10946.44,"providers":[{"billed_charge":49930.00,"npi":[1700950060]}]}]},{"tin":{"type":"ein","value":"344429514"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1178.14,"providers":[{"billed_charge":2258.00,"npi":[1942267760]}]}]},{"tin":{"type":"ein","value":"384105653"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1945.70,"providers":[{"billed_charge":9975.00,"npi":[1326020447]}]}]},{"tin":{"type":"ein","value":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":39798.99,"providers":[{"billed_charge":175682.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"314379509"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":393.58,"providers":[{"billed_charge":2795.76,"npi":[1215936927]}]}]},{"tin":{"type":"ein","value":"250523970"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1861.44,"providers":[{"billed_charge":2073.00,"npi":[1225048838]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":8395.20,"providers":[{"billed_charge":29225.00,"npi":[1467484972]}]},{"allowed_amount":51965.22,"providers":[{"billed_charge":218695.00,"npi":[1255377149]}]},{"allowed_amount":13634.14,"providers":[{"billed_charge":43045.00,"npi":[1972535052]}]},{"allowed_amount":9101.62,"providers":[{"billed_charge":57855.00,"npi":[1801937008]}]}]},{"tin":{"type":"ein","value":"311439334"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4358.59,"providers":[{"billed_charge":25831.00,"npi":[1982784534]}]},{"allowed_amount":12798.67,"providers":[{"billed_charge":67390.00,"npi":[1417037045]}]},{"allowed_amount":735.76,"providers":[{"billed_charge":4926.00,"npi":[1710067376]}]}]}]},{"name":"URGENT CARE","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"456","description":"EMERGENCY ROOM - URGENT CARE","allowed_amounts":[{"tin":{"type":"ein","value":"310833936"},"service_code":["20"],"billing_class":"institutional","payments":[{"allowed_amount":1634.13,"providers":[{"billed_charge":11460.00,"npi":[1548212988]}]}]}]},{"name":"CLINIC","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"510","description":"CLINIC - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":637.20,"providers":[{"billed_charge":660.00,"npi":[1234567893]}]}]}]},{"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":"341883132"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":1564.34,"providers":[{"billed_charge":11306.00,"npi":[1598765539]}]},{"allowed_amount":7.22,"providers":[{"billed_charge":285.00,"npi":[1598765539]}]}]},{"tin":{"type":"ein","value":"314391798"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":95.71,"providers":[{"billed_charge":319.00,"npi":[1346247350]}]}]},{"tin":{"type":"ein","value":"474442902"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":30.09,"providers":[{"billed_charge":361.00,"npi":[1346607017]}]}]},{"tin":{"type":"ein","value":"340733166"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":904.34,"providers":[{"billed_charge":4912.35,"npi":[1083696710]}]}]},{"tin":{"type":"ein","value":"340714755"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":28.50,"providers":[{"billed_charge":4093.50,"npi":[1396765681]}]}]},{"tin":{"type":"ein","value":"340714456"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":21.04,"providers":[{"billed_charge":143.70,"npi":[1790837235]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3945.80,"providers":[{"billed_charge":26327.75,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"311724085"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":420.01,"providers":[{"billed_charge":1046.65,"npi":[1669410940]}]}]},{"tin":{"type":"ein","value":"340714585"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":31275.41,"providers":[{"billed_charge":55211.00,"npi":[1679525919]}]},{"allowed_amount":862.10,"providers":[{"billed_charge":6133.65,"npi":[1679525919]}]}]},{"tin":{"type":"ein","value":"311480941"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":512.33,"providers":[{"billed_charge":12715.96,"npi":[1598868655]}]},{"allowed_amount":140.19,"providers":[{"billed_charge":263.69,"npi":[1598868655]}]}]},{"tin":{"type":"ein","value":"340714771"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":149.16,"providers":[{"billed_charge":580.90,"npi":[1871606921]}]}]},{"tin":{"type":"ein","value":"344429514"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":96.28,"providers":[{"billed_charge":262.35,"npi":[1942267760]}]}]},{"tin":{"type":"ein","value":"311079309"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":284.65,"providers":[{"billed_charge":733.60,"npi":[1700950060]}]}]},{"tin":{"type":"ein","value":"310833936"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":174.27,"providers":[{"billed_charge":889.91,"npi":[1548212988]}]}]},{"tin":{"type":"ein","value":"340714593"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":38.89,"providers":[{"billed_charge":68.60,"npi":[1598719346]}]}]},{"tin":{"type":"ein","value":"314446959"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":134.10,"providers":[{"billed_charge":465.18,"npi":[1710913462]}]}]},{"tin":{"type":"ein","value":"384105653"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":250.51,"providers":[{"billed_charge":1770.47,"npi":[1326020447]}]}]},{"tin":{"type":"ein","value":"314379436"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3.46,"providers":[{"billed_charge":43.90,"npi":[1235174327]}]}]},{"tin":{"type":"ein","value":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":611.15,"providers":[{"billed_charge":2293.95,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":0.68,"providers":[{"billed_charge":22.35,"npi":[1234567893]}]},{"allowed_amount":22.58,"providers":[{"billed_charge":806.53,"npi":[1234567893]}]}]},{"tin":{"type":"ein","value":"340714618"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2.32,"providers":[{"billed_charge":5.50,"npi":[1215989611]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":272.33,"providers":[{"billed_charge":824.40,"npi":[1972535052]}]},{"allowed_amount":673.49,"providers":[{"billed_charge":5033.55,"npi":[1801937008]}]},{"allowed_amount":10423.28,"providers":[{"billed_charge":23080.30,"npi":[1255377149]}]},{"allowed_amount":113.57,"providers":[{"billed_charge":713.27,"npi":[1467484972]}]}]},{"tin":{"type":"ein","value":"310653685"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4.00,"providers":[{"billed_charge":4.00,"npi":[1225053119]}]}]},{"tin":{"type":"ein","value":"311439334"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":169.22,"providers":[{"billed_charge":358.90,"npi":[1417037045]}]},{"allowed_amount":1.55,"providers":[{"billed_charge":9.05,"npi":[1982784534]}]}]}]},{"name":"HOSPICE/RTN HOME","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"651","description":"HOSPICE SERVICES - ROUTINE HOME CARE","allowed_amounts":[{"tin":{"type":"ein","value":"341788398"},"service_code":["34"],"billing_class":"institutional","payments":[{"allowed_amount":2184.00,"providers":[{"billed_charge":2811.90,"npi":[1104525617]}]}]}]},{"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":"310537504"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1022.55,"providers":[{"billed_charge":2555.00,"npi":[1073688354]}]}]},{"tin":{"type":"ein","value":"340714478"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2458.35,"providers":[{"billed_charge":9234.00,"npi":[1821035940]}]}]},{"tin":{"type":"ein","value":"314394942"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":247.06,"providers":[{"billed_charge":306.00,"npi":[1255377149]}]}]}]},{"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":"341029988"},"service_code":["22","19"],"billing_class":"professional","payments":[{"allowed_amount":34.71,"providers":[{"billed_charge":87.00,"npi":[1730642802]}]}]},{"tin":{"type":"ein","value":"310745303"},"service_code":["11","22","15"],"billing_class":"professional","payments":[{"allowed_amount":108.50,"providers":[{"billed_charge":375.00,"npi":[1407834963]}]},{"allowed_amount":43.40,"providers":[{"billed_charge":150.00,"npi":[1407834963]}]},{"allowed_amount":683.54,"providers":[{"billed_charge":2475.00,"npi":[1407834963]}]}]}]},{"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":"310745303"},"service_code":["11","22","15"],"billing_class":"professional","payments":[{"allowed_amount":137.20,"providers":[{"billed_charge":675.00,"npi":[1407834963]}]},{"allowed_amount":836.92,"providers":[{"billed_charge":4320.00,"npi":[1407834963]}]},{"allowed_amount":82.32,"providers":[{"billed_charge":405.00,"npi":[1407834963]}]}]},{"tin":{"type":"ein","value":"341029988"},"service_code":["22","19"],"billing_class":"professional","payments":[{"allowed_amount":43.90,"providers":[{"billed_charge":66.00,"npi":[1730642802]}]}]},{"tin":{"type":"ein","value":"341843192"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":917.15,"providers":[{"billed_charge":4004.00,"npi":[1891794970]}]}]}]},{"name":"DXA BONE DENSITY, AXIAL","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"77080","description":"DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIP","allowed_amounts":[{"tin":{"type":"ein","value":"310745303"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":95.16,"providers":[{"billed_charge":2522.00,"npi":[1821209115]}]}]}]},{"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":"340714585"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":339.00,"providers":[{"billed_charge":598.00,"npi":[1124010954]}]}]},{"tin":{"type":"ein","value":"550357057"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":160.29,"providers":[{"billed_charge":627.00,"npi":[1720615545]}]}]}]},{"name":"COMPREHEN METABOLIC PANEL","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"80053","description":"COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTA","allowed_amounts":[{"tin":{"type":"ein","value":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":768.56,"providers":[{"billed_charge":1647.36,"npi":[1811154388]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":84.68,"providers":[{"billed_charge":880.29,"npi":[1234567893]}]}]}]},{"name":"LIPID PANEL","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"80061","description":"LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DI","allowed_amounts":[{"tin":{"type":"ein","value":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":543.75,"providers":[{"billed_charge":1164.93,"npi":[1811154388]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.12,"providers":[{"billed_charge":536.12,"npi":[1234567893]}]}]}]},{"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":"43110360"},"service_code":["65"],"billing_class":"institutional","payments":[{"allowed_amount":38940.00,"providers":[{"billed_charge":388608.00,"npi":[1184739948]}]}]}]},{"name":"VITAMIN D 25 HYDROXY","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"82306","description":"VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED","allowed_amounts":[{"tin":{"type":"ein","value":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":663.04,"providers":[{"billed_charge":1420.80,"npi":[1811154388]}]}]}]},{"name":"GLYCOSYLATED HEMOGLOBIN TEST","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"83036","description":"HEMOGLOBIN; GLYCOSYLATED (A1C)","allowed_amounts":[{"tin":{"type":"ein","value":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":176.67,"providers":[{"billed_charge":378.69,"npi":[1811154388]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":20.72,"providers":[{"billed_charge":272.84,"npi":[1234567893]}]}]}]},{"name":"ASSAY THYROID STIM HORMONE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"84443","description":"THYROID STIMULATING HORMONE (TSH)","allowed_amounts":[{"tin":{"type":"ein","value":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":635.04,"providers":[{"billed_charge":1360.80,"npi":[1811154388]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":73.41,"providers":[{"billed_charge":700.50,"npi":[1234567893]}]}]}]},{"name":"COMPLETE CBC W/AUTO DIFF WBC","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"85025","description":"BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED DIFFERE","allowed_amounts":[{"tin":{"type":"ein","value":"610445850"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":228.48,"providers":[{"billed_charge":489.51,"npi":[1811154388]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":43.58,"providers":[{"billed_charge":342.56,"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":"832279745"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":118.32,"providers":[{"billed_charge":196.00,"npi":[1831514025]}]}]},{"tin":{"type":"ein","value":"310744468"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":131.61,"providers":[{"billed_charge":450.00,"npi":[1750542171]}]}]},{"tin":{"type":"ein","value":"341952521"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":42.43,"providers":[{"billed_charge":233.58,"npi":[1245441310]}]}]},{"tin":{"type":"ein","value":"341362299"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":205.08,"providers":[{"billed_charge":1920.00,"npi":[1194982389]}]}]}]},{"name":"ELECTRO SHOCK","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"901","description":"PSYCHIATRIC/PSYCHOLOGICAL TREATMENTS - ELECTROSCHOCK TREATMENT","allowed_amounts":[{"tin":{"type":"ein","value":"340714755"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":11318.32,"providers":[{"billed_charge":25306.00,"npi":[1396765681]}]}]}]},{"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":"882468918"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":4365.09,"providers":[{"billed_charge":137700.00,"npi":[1477277416]}]}]}]},{"name":"PSYTX W PT 30 MINUTES","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90832","description":"PSYCHOTHERAPY, 30 MINUTES WITH PATIENT","allowed_amounts":[{"tin":{"type":"ein","value":"341609341"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":521.95,"providers":[{"billed_charge":900.00,"npi":[1871028142]}]}]}]},{"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":"880954473"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":100.91,"providers":[{"billed_charge":120.00,"npi":[1679056261]}]},{"allowed_amount":4320.00,"providers":[{"billed_charge":4320.00,"npi":[1679056261]}]}]},{"tin":{"type":"ein","value":"821885970"},"service_code":["11","02"],"billing_class":"professional","payments":[{"allowed_amount":245.28,"providers":[{"billed_charge":400.00,"npi":[1841785698]}]},{"allowed_amount":100.91,"providers":[{"billed_charge":200.00,"npi":[1841785698]}]}]},{"tin":{"type":"ein","value":"822787692"},"service_code":["11","02"],"billing_class":"professional","payments":[{"allowed_amount":170.82,"providers":[{"billed_charge":290.00,"npi":[1790665016]}]},{"allowed_amount":84.97,"providers":[{"billed_charge":145.00,"npi":[1790665016]}]}]},{"tin":{"type":"ein","value":"863277318"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":490.56,"providers":[{"billed_charge":700.00,"npi":[1134894744]}]}]},{"tin":{"type":"ein","value":"341790929"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1326.83,"providers":[{"billed_charge":2700.00,"npi":[1316328180]}]}]},{"tin":{"type":"ein","value":"263607741"},"service_code":["11","50"],"billing_class":"professional","payments":[{"allowed_amount":735.84,"providers":[{"billed_charge":1098.00,"npi":[1770771131]}]},{"allowed_amount":122.64,"providers":[{"billed_charge":183.00,"npi":[1770771131]}]}]},{"tin":{"type":"ein","value":"861240671"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":1471.63,"providers":[{"billed_charge":1500.00,"npi":[1881064111]}]},{"allowed_amount":100.91,"providers":[{"billed_charge":125.00,"npi":[1881064111]}]}]},{"tin":{"type":"ein","value":"999999999"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":5970.25,"providers":[{"billed_charge":11306.25,"npi":[1234567893]}]}]}]},{"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":"842897979"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":3370.72,"providers":[{"billed_charge":10560.00,"npi":[1922607266]}]}]}]},{"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":"340714357"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":668.40,"providers":[{"billed_charge":1568.50,"npi":[1861506560]}]}]},{"tin":{"type":"ein","value":"344428218"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":2326.20,"providers":[{"billed_charge":3766.98,"npi":[1801884655]}]}]},{"tin":{"type":"ein","value":"340967014"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":1510.11,"providers":[{"billed_charge":4389.00,"npi":[1811971302]}]}]}]},{"name":"PSTAY/GROUP RX","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"915","description":"PSYCHIATRIC/PSYCHOLOGICAL SERVICES - GROUP THERAPY","allowed_amounts":[{"tin":{"type":"ein","value":"310621866"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":701.54,"providers":[{"billed_charge":3598.00,"npi":[1316966518]}]}]},{"tin":{"type":"ein","value":"340714755"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":11045.47,"providers":[{"billed_charge":25141.50,"npi":[1396765681]}]}]},{"tin":{"type":"ein","value":"311340739"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":1814.90,"providers":[{"billed_charge":10944.00,"npi":[1447359997]}]}]}]},{"name":"AEP SCR AUDITORY POTENTIAL","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"92650","description":"AEP SCR AUDITORY POTENTIAL W/STIMULI AUTO ALYS","allowed_amounts":[{"tin":{"type":"ein","value":"311439157"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":132.02,"providers":[{"billed_charge":1750.00,"npi":[1528211992]}]}]}]},{"name":"ELECTROCARDIOGRAM REPORT","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"93010","description":"ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY","allowed_amounts":[{"tin":{"type":"ein","value":"851040784"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":25.38,"providers":[{"billed_charge":36.00,"npi":[1952895716]}]}]}]},{"name":"IMMUNOTHERAPY, ONE INJECTION","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"95115","description":"PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SIN","allowed_amounts":[{"tin":{"type":"ein","value":"204786083"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":38.04,"providers":[{"billed_charge":92.00,"npi":[1881660249]}]}]}]},{"name":"IMMUNOTHERAPY INJECTIONS","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"95117","description":"PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 2 O","allowed_amounts":[{"tin":{"type":"ein","value":"204786083"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":147.55,"providers":[{"billed_charge":325.00,"npi":[1881660249]}]}]}]},{"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":"341810495"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":735.76,"providers":[{"billed_charge":2013.00,"npi":[1063462505]}]}]},{"tin":{"type":"ein","value":"341222395"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":200.67,"providers":[{"billed_charge":432.00,"npi":[1578010625]}]}]}]},{"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":"341810495"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":125.50,"providers":[{"billed_charge":350.00,"npi":[1063462505]}]}]}]},{"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":"341810495"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":404.14,"providers":[{"billed_charge":1064.00,"npi":[1063462505]}]}]}]},{"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":"69927790"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":18154.37,"providers":[{"billed_charge":36864.00,"npi":[1245866763]}]}]},{"tin":{"type":"ein","value":"922089637"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":12704.65,"providers":[{"billed_charge":26550.00,"npi":[1194133447]}]}]},{"tin":{"type":"ein","value":"202605791"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":3938.02,"providers":[{"billed_charge":8650.00,"npi":[1700380532]}]}]}]},{"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":"922089637"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":416.48,"providers":[{"billed_charge":1800.00,"npi":[1194133447]}]}]}]},{"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":"743056785"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":103.53,"providers":[{"billed_charge":165.00,"npi":[1942367537]}]}]},{"tin":{"type":"ein","value":"341941092"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":690.20,"providers":[{"billed_charge":1200.00,"npi":[1811002637]}]}]}]},{"name":"OFFICE/OUTPATIENT VISIT NEW","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99202","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":["10"],"billing_class":"professional","payments":[{"allowed_amount":1030.00,"providers":[{"billed_charge":2660.00,"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":"203113336"},"service_code":["17","10"],"billing_class":"professional","payments":[{"allowed_amount":127.57,"providers":[{"billed_charge":322.00,"npi":[1699747303]}]},{"allowed_amount":1685.87,"providers":[{"billed_charge":5798.73,"npi":[1699747303]}]}]}]},{"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":"275349332"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":551.80,"providers":[{"billed_charge":1060.00,"npi":[1407712300]}]}]},{"tin":{"type":"ein","value":"346565185"},"service_code":["50"],"billing_class":"professional","payments":[{"allowed_amount":441.44,"providers":[{"billed_charge":704.00,"npi":[1427849645]}]}]}]},{"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":"821185004"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":143.26,"providers":[{"billed_charge":278.00,"npi":[1558354977]}]}]},{"tin":{"type":"ein","value":"341973127"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":429.78,"providers":[{"billed_charge":540.00,"npi":[1417930165]}]}]},{"tin":{"type":"ein","value":"260822646"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":347.72,"providers":[{"billed_charge":420.00,"npi":[1740347566]}]}]},{"tin":{"type":"ein","value":"341706671"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":143.26,"providers":[{"billed_charge":260.00,"npi":[1659348563]}]}]}]},{"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":"842128424"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":210.26,"providers":[{"billed_charge":422.00,"npi":[1760904494]}]}]},{"tin":{"type":"ein","value":"463950395"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":1577.06,"providers":[{"billed_charge":2040.00,"npi":[1184908295]}]}]}]},{"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":"346401447"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":32.96,"providers":[{"billed_charge":164.80,"npi":[1164598769]}]}]}]},{"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":1071.36,"providers":[{"billed_charge":2626.80,"npi":[1234567893]}]}]}]},{"name":"PA;PRD Q PERS DET APPR COMB","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"G2077","description":"PA;ASSESS PRD Q PERS DET MOST APPR COMB SRVC&TX","allowed_amounts":[{"tin":{"type":"ein","value":"472519577"},"service_code":["58"],"billing_class":"professional","payments":[{"allowed_amount":1020.95,"providers":[{"billed_charge":1225.00,"npi":[1659769446]}]}]}]}]}