{"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":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":45.14,"providers":[{"billed_charge":96.74,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":18.81,"providers":[{"billed_charge":415.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":47.27,"providers":[{"billed_charge":462.69,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":94.51,"providers":[{"billed_charge":2614.56,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":116.29,"providers":[{"billed_charge":838.39,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":9.93,"providers":[{"billed_charge":11.32,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7.20,"providers":[{"billed_charge":7.20,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":18.99,"providers":[{"billed_charge":184.24,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1.37,"providers":[{"billed_charge":4.25,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":28.03,"providers":[{"billed_charge":498.00,"npi":[1215042114]}]},{"allowed_amount":4.11,"providers":[{"billed_charge":315.00,"npi":[1508971441]}]},{"allowed_amount":74.65,"providers":[{"billed_charge":910.00,"npi":[1245335629]}]}]},{"tin":{"type":"ein","value":"934487584"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":42.24,"providers":[{"billed_charge":528.40,"npi":[1699515304]}]}]}]},{"name":"DRUGS/INCIDNT RAD","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"255","description":"PHARMACY - DRUGS INCIDENT TO RADIOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":881.79,"providers":[{"billed_charge":881.79,"npi":[1699734665]}]}]}]},{"name":"IV SOLUTIONS","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"258","description":"PHARMACY - IV SOLUTIONS","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":25.01,"providers":[{"billed_charge":163.53,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6.20,"providers":[{"billed_charge":200.00,"npi":[1245335629]}]}]}]},{"name":"IV THERAPY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"260","description":"IV THERAPY - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":991.60,"providers":[{"billed_charge":5424.00,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":693.13,"providers":[{"billed_charge":1973.00,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2814.40,"providers":[{"billed_charge":17386.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6700.99,"providers":[{"billed_charge":44174.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":103.42,"providers":[{"billed_charge":1669.00,"npi":[1568435477]}]},{"allowed_amount":1171.20,"providers":[{"billed_charge":10002.00,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"934487584"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":325.24,"providers":[{"billed_charge":1065.24,"npi":[1699515304]}]}]}]},{"name":"LABORATORY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"300","description":"LABORATORY - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"231352213"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":36.83,"providers":[{"billed_charge":195.00,"npi":[1376339226]}]},{"allowed_amount":61.00,"providers":[{"billed_charge":247.00,"npi":[1013933175]}]},{"allowed_amount":229.70,"providers":[{"billed_charge":1011.00,"npi":[1952399933]}]}]},{"tin":{"type":"ein","value":"231352203"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":550.41,"providers":[{"billed_charge":3526.00,"npi":[1669405072]}]}]},{"tin":{"type":"ein","value":"231352166"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":4335.94,"providers":[{"billed_charge":22075.40,"npi":[1215921457]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":10177.62,"providers":[{"billed_charge":21782.01,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":57.72,"providers":[{"billed_charge":392.00,"npi":[1568435477]}]},{"allowed_amount":4328.08,"providers":[{"billed_charge":11247.00,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"844475996"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":164.49,"providers":[{"billed_charge":695.00,"npi":[1073047981]}]}]},{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":19.47,"providers":[{"billed_charge":38.25,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2987.34,"providers":[{"billed_charge":15394.00,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3021.41,"providers":[{"billed_charge":12456.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":71.39,"providers":[{"billed_charge":396.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1067.42,"providers":[{"billed_charge":11684.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1559.09,"providers":[{"billed_charge":13582.00,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":19.47,"providers":[{"billed_charge":78.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"465143606"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":88.45,"providers":[{"billed_charge":323.00,"npi":[1396194197]}]}]},{"tin":{"type":"ein","value":"934487584"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2777.80,"providers":[{"billed_charge":10793.58,"npi":[1699515304]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":465.72,"providers":[{"billed_charge":1337.00,"npi":[1215042114]}]},{"allowed_amount":481.28,"providers":[{"billed_charge":1465.00,"npi":[1245335629]}]}]}]},{"name":"LAB/CHEMISTRY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"301","description":"LABORATORY - CHEMISTRY","allowed_amounts":[{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2249.57,"providers":[{"billed_charge":4042.00,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":117.11,"providers":[{"billed_charge":501.00,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1809.84,"providers":[{"billed_charge":8928.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1957.59,"providers":[{"billed_charge":2464.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":9828.23,"providers":[{"billed_charge":224721.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":14983.06,"providers":[{"billed_charge":22849.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"250965588"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":236.95,"providers":[{"billed_charge":311.00,"npi":[1871594127]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2108.19,"providers":[{"billed_charge":47943.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2014.86,"providers":[{"billed_charge":3066.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3493.58,"providers":[{"billed_charge":18341.00,"npi":[1215042114]}]},{"allowed_amount":281.37,"providers":[{"billed_charge":4729.00,"npi":[1508971441]}]},{"allowed_amount":2916.40,"providers":[{"billed_charge":20876.00,"npi":[1245335629]}]}]}]},{"name":"LAB/HEMATOLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"305","description":"LABORATORY - HEMATOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":197.67,"providers":[{"billed_charge":416.00,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":591.70,"providers":[{"billed_charge":1683.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":577.34,"providers":[{"billed_charge":807.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2002.14,"providers":[{"billed_charge":36259.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3751.54,"providers":[{"billed_charge":5310.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":257.93,"providers":[{"billed_charge":808.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":273.15,"providers":[{"billed_charge":5242.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":696.34,"providers":[{"billed_charge":2105.00,"npi":[1245335629]}]},{"allowed_amount":580.79,"providers":[{"billed_charge":1816.00,"npi":[1215042114]}]}]}]},{"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":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":423.04,"providers":[{"billed_charge":12476.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":439.23,"providers":[{"billed_charge":784.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":117.57,"providers":[{"billed_charge":167.00,"npi":[1083615587]}]}]}]},{"name":"LAB/UROLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"307","description":"LABORATORY - UROLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":843.51,"providers":[{"billed_charge":870.00,"npi":[1699734665]}]}]}]},{"name":"DX X-RAY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"320","description":"RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":1767.04,"providers":[{"billed_charge":22317.00,"npi":[1962579029]}]},{"allowed_amount":587.42,"providers":[{"billed_charge":3846.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":247.88,"providers":[{"billed_charge":2921.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":446.60,"providers":[{"billed_charge":1900.00,"npi":[1215042114]}]},{"allowed_amount":64.42,"providers":[{"billed_charge":601.00,"npi":[1245335629]}]}]}]},{"name":"DX X-RAY/CHEST","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"324","description":"RADIOLOGY - DIAGNOSTIC - CHEST X-RAY","allowed_amounts":[{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2063.06,"providers":[{"billed_charge":12760.00,"npi":[1699734665]}]}]}]},{"name":"CT SCAN","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"350","description":"CT SCAN - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":5557.38,"providers":[{"billed_charge":46749.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3248.21,"providers":[{"billed_charge":14687.00,"npi":[1245335629]}]}]}]},{"name":"CT SCAN/HEAD","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"351","description":"CT SCAN - HEAD SCAN","allowed_amounts":[{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":423.21,"providers":[{"billed_charge":532.00,"npi":[1699734665]}]}]}]},{"name":"CT SCAN/BODY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"352","description":"CT SCAN - BODY SCAN","allowed_amounts":[{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":14573.72,"providers":[{"billed_charge":25182.00,"npi":[1699734665]}]}]}]},{"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":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":93.60,"providers":[{"billed_charge":1028.40,"npi":[1234567893]}]}]}]},{"name":"BLOOD/STOR-PROC","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"390","description":"BLOOD STORAGE AND PROCESSING - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":20.09,"providers":[{"billed_charge":113.00,"npi":[1962579029]}]}]}]},{"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":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":57132.82,"providers":[{"billed_charge":384873.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":703.46,"providers":[{"billed_charge":5536.00,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4717.20,"providers":[{"billed_charge":26163.00,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1699.41,"providers":[{"billed_charge":14190.00,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6346.99,"providers":[{"billed_charge":37731.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6912.82,"providers":[{"billed_charge":45209.00,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":28895.85,"providers":[{"billed_charge":516147.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"250965588"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4457.67,"providers":[{"billed_charge":11666.00,"npi":[1871594127]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1491.68,"providers":[{"billed_charge":16313.00,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6309.54,"providers":[{"billed_charge":37396.00,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6143.88,"providers":[{"billed_charge":103284.00,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"934487584"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6717.16,"providers":[{"billed_charge":28799.13,"npi":[1699515304]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":15467.36,"providers":[{"billed_charge":87150.00,"npi":[1245335629]}]},{"allowed_amount":3143.14,"providers":[{"billed_charge":20233.00,"npi":[1508971441]}]},{"allowed_amount":10272.09,"providers":[{"billed_charge":56841.00,"npi":[1215042114]}]}]}]},{"name":"RURAL/CLINIC","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"521","description":"FREE-STANDING CLINIC - RURAL HEALTH-CLINIC","allowed_amounts":[{"tin":{"type":"ein","value":"231909490"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":4922.08,"providers":[{"billed_charge":13810.80,"npi":[1770288698]}]},{"allowed_amount":398.88,"providers":[{"billed_charge":1494.00,"npi":[1396440244]}]}]},{"tin":{"type":"ein","value":"232180889"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":199.41,"providers":[{"billed_charge":198.00,"npi":[1407091077]}]}]}]},{"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":"231352155"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":12708.39,"providers":[{"billed_charge":179577.15,"npi":[1649278730]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":3642.14,"providers":[{"billed_charge":27013.09,"npi":[1699734665]}]},{"allowed_amount":1024.66,"providers":[{"billed_charge":5621.45,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"844475996"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":36.57,"providers":[{"billed_charge":64.66,"npi":[1073047981]}]}]},{"tin":{"type":"ein","value":"251854772"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":44.35,"providers":[{"billed_charge":91.19,"npi":[1568435477]}]}]},{"tin":{"type":"ein","value":"820844453"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":215.74,"providers":[{"billed_charge":844.85,"npi":[1285167916]}]}]},{"tin":{"type":"ein","value":"251550350"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":390.56,"providers":[{"billed_charge":700.49,"npi":[1437182847]}]}]},{"tin":{"type":"ein","value":"231529076"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":435.28,"providers":[{"billed_charge":2080.00,"npi":[1407856099]}]}]},{"tin":{"type":"ein","value":"851620990"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":735.25,"providers":[{"billed_charge":1846.96,"npi":[1013674266]}]}]},{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":912.08,"providers":[{"billed_charge":4494.37,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"824432109"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":672.63,"providers":[{"billed_charge":1947.71,"npi":[1265096069]}]}]},{"tin":{"type":"ein","value":"883577015"},"service_code":["22","23"],"billing_class":"institutional","payments":[{"allowed_amount":1.50,"providers":[{"billed_charge":2221.84,"npi":[1437865953]}]},{"allowed_amount":215.21,"providers":[{"billed_charge":1083.05,"npi":[1437865953]}]}]},{"tin":{"type":"ein","value":"231370484"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":469.69,"providers":[{"billed_charge":1012.50,"npi":[1083615587]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":441.82,"providers":[{"billed_charge":1734.00,"npi":[1215042114]}]},{"allowed_amount":1340.35,"providers":[{"billed_charge":8061.00,"npi":[1245335629]}]}]}]},{"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":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3006.82,"providers":[{"billed_charge":19854.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2856.78,"providers":[{"billed_charge":12738.00,"npi":[1699734665]}]}]},{"tin":{"type":"ein","value":"231352160"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":87.23,"providers":[{"billed_charge":653.00,"npi":[1245335629]}]}]}]},{"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":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":95.31,"providers":[{"billed_charge":1140.48,"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":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":89.76,"providers":[{"billed_charge":1066.98,"npi":[1234567893]}]}]}]},{"name":"URINALYSIS AUTO W/SCOPE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"81001","description":"URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, ","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":4.24,"providers":[{"billed_charge":50.72,"npi":[1234567893]}]}]}]},{"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":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":128.57,"providers":[{"billed_charge":1539.20,"npi":[1234567893]}]}]}]},{"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":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":19.44,"providers":[{"billed_charge":233.04,"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":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":95.82,"providers":[{"billed_charge":1117.20,"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":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":61.07,"providers":[{"billed_charge":625.50,"npi":[1234567893]}]}]}]},{"name":"BH/INTENS OP/CHEM DEP","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"906","description":"INTENSIVE OUTPATIENT SERVICES - CHEMICAL DEPENDENCY","allowed_amounts":[{"tin":{"type":"ein","value":"863916163"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":1778.71,"providers":[{"billed_charge":42500.00,"npi":[1023688157]}]}]},{"tin":{"type":"ein","value":"831651485"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":16000.00,"providers":[{"billed_charge":134080.00,"npi":[1801360573]}]}]}]},{"name":"PSYTX W PT W E/M 30 MIN","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90833","description":"PSYCHOTHERAPY, 30 MINUTES WITH PATIENT WHEN PERFORMED WITH AN EVALUATION AND MANAGEMENT SERVICE","allowed_amounts":[{"tin":{"type":"ein","value":"465013529"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":1993.19,"providers":[{"billed_charge":3384.00,"npi":[1740775444]}]},{"allowed_amount":134.77,"providers":[{"billed_charge":188.00,"npi":[1740775444]}]}]}]},{"name":"PSYTX W PT 60 MINUTES","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90837","description":"PSYCHOTHERAPY, 60 MINUTES WITH PATIENT","allowed_amounts":[{"tin":{"type":"ein","value":"811894745"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":1380.20,"providers":[{"billed_charge":2250.00,"npi":[1073987186]}]}]},{"tin":{"type":"ein","value":"332897648"},"service_code":["02"],"billing_class":"professional","payments":[{"allowed_amount":100.91,"providers":[{"billed_charge":130.00,"npi":[1124870555]}]}]},{"tin":{"type":"ein","value":"871904636"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":3763.10,"providers":[{"billed_charge":4400.00,"npi":[1194140848]}]},{"allowed_amount":2622.38,"providers":[{"billed_charge":3800.00,"npi":[1194140848]}]}]},{"tin":{"type":"ein","value":"263447487"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":4243.91,"providers":[{"billed_charge":10250.00,"npi":[1295598746]}]},{"allowed_amount":898.03,"providers":[{"billed_charge":1750.00,"npi":[1982384970]}]},{"allowed_amount":1345.63,"providers":[{"billed_charge":3250.00,"npi":[1982384970]}]},{"allowed_amount":1242.12,"providers":[{"billed_charge":3000.00,"npi":[1396629556]}]},{"allowed_amount":2565.80,"providers":[{"billed_charge":5000.00,"npi":[1396629556]}]}]},{"tin":{"type":"ein","value":"832507546"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":1670.00,"providers":[{"billed_charge":3510.00,"npi":[1831513886,1093588725]}]},{"allowed_amount":1336.00,"providers":[{"billed_charge":2808.00,"npi":[1205675550]}]},{"allowed_amount":501.00,"providers":[{"billed_charge":1053.00,"npi":[1356838395,1881686012]}]}]},{"tin":{"type":"ein","value":"851573924"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":1227.60,"providers":[{"billed_charge":1900.00,"npi":[1477348258]}]}]},{"tin":{"type":"ein","value":"333112370"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":358.62,"providers":[{"billed_charge":358.62,"npi":[1497434658]}]}]}]},{"name":"PSTAY/PARTIAL HOSP","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"912","description":"PSYCHIATRIC/PSYCHOLOGICAL SERVICES - PARTIAL HOSPITALIZATION","allowed_amounts":[{"tin":{"type":"ein","value":"863916163"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":2317.95,"providers":[{"billed_charge":31500.00,"npi":[1023688157]}]}]},{"tin":{"type":"ein","value":"831651485"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":3675.00,"providers":[{"billed_charge":16765.00,"npi":[1801360573]}]}]}]},{"name":"OTHER RX SVS","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"940","description":"OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"232825878"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":722.59,"providers":[{"billed_charge":9462.00,"npi":[1962579029]}]}]},{"tin":{"type":"ein","value":"231352211"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":175.68,"providers":[{"billed_charge":1226.00,"npi":[1699734665]}]}]}]},{"name":"OFFICE/OUTPATIENT VISIT EST","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99213","description":"OFFICE OR OTH OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH RE","allowed_amounts":[{"tin":{"type":"ein","value":"842407118"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":197.10,"providers":[{"billed_charge":240.00,"npi":[1073781621]}]}]}]},{"name":"OFFICE/OUTPATIENT VISIT EST","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99214","description":"OFFICE OR OTH OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH RE","allowed_amounts":[{"tin":{"type":"ein","value":"263447487"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":74.12,"providers":[{"billed_charge":185.00,"npi":[1740994599]}]}]},{"tin":{"type":"ein","value":"465013529"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":330.09,"providers":[{"billed_charge":594.00,"npi":[1740775444]}]},{"allowed_amount":2326.61,"providers":[{"billed_charge":6534.00,"npi":[1740775444]}]}]}]},{"name":"GRND MLGE PER STATUTE MILE","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A0425","description":"GROUND MILEAGE, PER STATUTE MILE","allowed_amounts":[{"tin":{"type":"ein","value":"232840702"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":109.05,"providers":[{"billed_charge":335.40,"npi":[1003819103]}]}]},{"tin":{"type":"ein","value":"236001907"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":356.23,"providers":[{"billed_charge":784.00,"npi":[1982601894]}]}]}]},{"name":"MENTAL HLTH PART HOSP TX <24","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"H0035","description":"MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS","allowed_amounts":[{"tin":{"type":"ein","value":"872635647"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1427.70,"providers":[{"billed_charge":23970.00,"npi":[1861651077]}]}]}]}]}