{"reporting_entity_name":"Centene Management Company LLC","reporting_entity_type":"Third Party Administrator","version":"1.0.0","last_updated_on":"2025-07-31","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":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2.40,"providers":[{"billed_charge":514.00,"npi":[1770626426]}]}]}]},{"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":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7183.52,"providers":[{"billed_charge":25567.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1888.71,"providers":[{"billed_charge":5865.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2836.30,"providers":[{"billed_charge":15265.00,"npi":[1922542968]}]},{"allowed_amount":1984.68,"providers":[{"billed_charge":6308.00,"npi":[1457895336]}]}]}]},{"name":"LABORATORY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"300","description":"LABORATORY - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":16.23,"providers":[{"billed_charge":122.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":158.33,"providers":[{"billed_charge":23024.00,"npi":[1740724780]}]},{"allowed_amount":288.78,"providers":[{"billed_charge":24118.00,"npi":[1578007514]}]},{"allowed_amount":1100.29,"providers":[{"billed_charge":92699.00,"npi":[1922542968]}]},{"allowed_amount":692.21,"providers":[{"billed_charge":81941.00,"npi":[1457895336]}]}]}]},{"name":"LAB/CHEMISTRY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"301","description":"LABORATORY - CHEMISTRY","allowed_amounts":[{"tin":{"type":"ein","value":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2533.18,"providers":[{"billed_charge":118219.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":251.72,"providers":[{"billed_charge":41073.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":34.56,"providers":[{"billed_charge":1569.00,"npi":[1285490292]}]}]}]},{"name":"LAB/IMMUNOLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"302","description":"LABORATORY - IMMUNOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":249.64,"providers":[{"billed_charge":24909.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":215.50,"providers":[{"billed_charge":8436.00,"npi":[1528101284]}]}]}]},{"name":"LAB/HEMATOLOGY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"305","description":"LABORATORY - HEMATOLOGY","allowed_amounts":[{"tin":{"type":"ein","value":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":368.17,"providers":[{"billed_charge":28357.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":75.41,"providers":[{"billed_charge":11019.00,"npi":[1528101284]}]}]}]},{"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":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":913.52,"providers":[{"billed_charge":25460.00,"npi":[1770626426]}]}]}]},{"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":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":987.50,"providers":[{"billed_charge":9656.00,"npi":[1770626426]}]}]}]},{"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":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1750.62,"providers":[{"billed_charge":47774.00,"npi":[1770626426]}]}]}]},{"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":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":34884.13,"providers":[{"billed_charge":164811.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"743048428"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3759.51,"providers":[{"billed_charge":47687.00,"npi":[1114576857]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":10677.08,"providers":[{"billed_charge":46536.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1260.68,"providers":[{"billed_charge":30661.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":19397.26,"providers":[{"billed_charge":47689.00,"npi":[1922542968]}]},{"allowed_amount":5149.47,"providers":[{"billed_charge":23848.00,"npi":[1457895336]}]}]}]},{"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":"860865357"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":1418.55,"providers":[{"billed_charge":2696.17,"npi":[1093421919]}]}]}]},{"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":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":431.79,"providers":[{"billed_charge":10021.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"743048428"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":44.59,"providers":[{"billed_charge":318.50,"npi":[1184476145]}]}]},{"tin":{"type":"ein","value":"851644866"},"service_code":["21"],"billing_class":"institutional","payments":[{"allowed_amount":5749.18,"providers":[{"billed_charge":19163.92,"npi":[1417554528]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":102.13,"providers":[{"billed_charge":3859.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":16.73,"providers":[{"billed_charge":718.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"946004062"},"service_code":["23","21"],"billing_class":"institutional","payments":[{"allowed_amount":463.20,"providers":[{"billed_charge":1544.00,"npi":[1538265780]}]},{"allowed_amount":191.25,"providers":[{"billed_charge":637.50,"npi":[1538265780]}]}]}]},{"name":"X-RAY EXAM CHEST 1 VIEW","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"71045","description":"RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW","allowed_amounts":[{"tin":{"type":"ein","value":"880113741"},"service_code":["23","21"],"billing_class":"professional","payments":[{"allowed_amount":6.69,"providers":[{"billed_charge":33.00,"npi":[1699955401]}]},{"allowed_amount":13.38,"providers":[{"billed_charge":66.00,"npi":[1699955401]}]}]}]},{"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":"880455713"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":366.83,"providers":[{"billed_charge":8606.00,"npi":[1770626426]}]}]}]},{"name":"CANDIDA, DNA, AMP PROBE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"87481","description":"INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CANDIDA SPECIES, AMPLIFIED PROBE TECHNIQUE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":234.40,"providers":[{"billed_charge":2600.00,"npi":[1234567893]}]}]}]},{"name":"CHYLMD TRACH, DNA, AMP PROBE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"87491","description":"INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECH","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":632.88,"providers":[{"billed_charge":7020.00,"npi":[1234567893]}]}]}]},{"name":"M. GENITALIUM AMP PROBE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"87563","description":"IADNA MYCOPLASMA GENITALIUM AMPLIFIED PROBE TECH","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":492.24,"providers":[{"billed_charge":5460.00,"npi":[1234567893]}]}]}]},{"name":"N.GONORRHOEAE, DNA, AMP PROB","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"87591","description":"INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECH","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":621.16,"providers":[{"billed_charge":6890.00,"npi":[1234567893]}]}]}]},{"name":"HPV HIGH-RISK TYPES","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"87624","description":"INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HUMAN PAPILLOMAVIRUS (HPV), HIGH-RISK TYPES","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":621.16,"providers":[{"billed_charge":9010.00,"npi":[1234567893]}]}]}]},{"name":"SARS-COV-2 COVID-19 AMP PRB","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"87635","description":"Infectious agent detection by nucleic acid (DNA or RNA); (SARS-CoV-2) [COVID-19], amplified probe te","allowed_amounts":[{"tin":{"type":"ein","value":"861048626"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":76.98,"providers":[{"billed_charge":450.00,"npi":[1164482147]}]}]}]},{"name":"DETECT AGENT NOS, DNA, AMP","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"87798","description":"INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; AMPLIFIED PROBE TE","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":925.88,"providers":[{"billed_charge":10270.00,"npi":[1234567893]}]}]}]},{"name":"INFLUENZA ASSAY W/OPTIC","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"87804","description":"INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; INFLUENZA","allowed_amounts":[{"tin":{"type":"ein","value":"861048626"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":124.14,"providers":[{"billed_charge":1100.00,"npi":[1164482147]}]}]}]},{"name":"CYTOPATH C/V AUTO FLUID REDO","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"88175","description":"CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY RPTNG SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED TH","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":622.30,"providers":[{"billed_charge":5250.00,"npi":[1234567893]}]}]}]},{"name":"PSTAY TREATMENT","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"900","description":"PSYCHIATRIC/PSYCHOLOGICAL TREATMENTS - GENERAL CLASSIFICATION","allowed_amounts":[{"tin":{"type":"ein","value":"880502320"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":6056.28,"providers":[{"billed_charge":11479.97,"npi":[1255360160]}]}]}]},{"name":"IMMUNIZATION ADMIN","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90471","description":"IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJE","allowed_amounts":[{"tin":{"type":"ein","value":"880151573"},"service_code":["71"],"billing_class":"professional","payments":[{"allowed_amount":837.00,"providers":[{"billed_charge":2260.00,"npi":[1205896248]}]}]}]},{"name":"IMMUNIZATION ADMIN EACH ADD","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90472","description":"IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJE","allowed_amounts":[{"tin":{"type":"ein","value":"880151573"},"service_code":["71"],"billing_class":"professional","payments":[{"allowed_amount":830.97,"providers":[{"billed_charge":1953.00,"npi":[1205896248]}]}]}]},{"name":"9VHPV VACCINE 3 DOSE IM","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90651","description":"HUMAN PAPILLOMAVIRUS VACCINE TYPES 6, 11, 16, 18, 31, 33, 45, 52, 58, NONAVALENT (9VHPV), 2 OR 3 DOS","allowed_amounts":[{"tin":{"type":"ein","value":"880151573"},"service_code":["71"],"billing_class":"professional","payments":[{"allowed_amount":549.04,"providers":[{"billed_charge":930.00,"npi":[1205896248]}]}]}]},{"name":"TDAP VACCINE 7 YRS/> IM","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90715","description":"TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), WHEN ADMINISTERED TO INDIVIDUALS","allowed_amounts":[{"tin":{"type":"ein","value":"880151573"},"service_code":["71"],"billing_class":"professional","payments":[{"allowed_amount":72.68,"providers":[{"billed_charge":178.00,"npi":[1205896248]}]}]}]},{"name":"VAR VACCINE LIVE SUBQ","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90716","description":"VARICELLA VIRUS VACCINE (VAR), LIVE, FOR SUBCUTANEOUS USE","allowed_amounts":[{"tin":{"type":"ein","value":"880151573"},"service_code":["71"],"billing_class":"professional","payments":[{"allowed_amount":653.08,"providers":[{"billed_charge":1100.00,"npi":[1205896248]}]}]}]},{"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":"822164388"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":800.93,"providers":[{"billed_charge":1794.00,"npi":[1497302962]}]}]}]},{"name":"PSYTX W PT 45 MINUTES","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90834","description":"PSYCHOTHERAPY, 45 MINUTES WITH PATIENT","allowed_amounts":[{"tin":{"type":"ein","value":"461482002"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":210.39,"providers":[{"billed_charge":450.00,"npi":[1215221957]}]}]}]},{"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":"651195763"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":115.42,"providers":[{"billed_charge":250.00,"npi":[1760950844]}]}]},{"tin":{"type":"ein","value":"461482002"},"service_code":["11","02"],"billing_class":"professional","payments":[{"allowed_amount":519.40,"providers":[{"billed_charge":1000.00,"npi":[1215221957]}]},{"allowed_amount":103.88,"providers":[{"billed_charge":200.00,"npi":[1215221957]}]}]}]},{"name":"GROUP PSYCHOTHERAPY","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90853","description":"GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP)","allowed_amounts":[{"tin":{"type":"ein","value":"880111970"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":588.84,"providers":[{"billed_charge":840.00,"npi":[1447558887]}]}]}]},{"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":"812931313"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":15041.52,"providers":[{"billed_charge":15600.00,"npi":[1972311090]}]}]}]},{"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":"861048626"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":4510.95,"providers":[{"billed_charge":6120.00,"npi":[1164482147]}]}]},{"tin":{"type":"ein","value":"880321712"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":464.37,"providers":[{"billed_charge":645.00,"npi":[1528218765]}]}]},{"tin":{"type":"ein","value":"204477738"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":707.60,"providers":[{"billed_charge":1824.00,"npi":[1619597580]}]}]}]},{"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":"463164188"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":661.00,"providers":[{"billed_charge":1670.00,"npi":[1316694037]}]},{"allowed_amount":264.40,"providers":[{"billed_charge":668.00,"npi":[1568008878]}]}]},{"tin":{"type":"ein","value":"862393949"},"service_code":["11","10"],"billing_class":"professional","payments":[{"allowed_amount":634.56,"providers":[{"billed_charge":900.00,"npi":[1629393632]}]},{"allowed_amount":317.28,"providers":[{"billed_charge":450.00,"npi":[1629393632]}]}]},{"tin":{"type":"ein","value":"822164388"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":846.08,"providers":[{"billed_charge":2656.00,"npi":[1497302962]}]}]},{"tin":{"type":"ein","value":"814113791"},"service_code":["11","02"],"billing_class":"professional","payments":[{"allowed_amount":105.76,"providers":[{"billed_charge":394.68,"npi":[1366035750]}]}]}]},{"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":"202367478"},"service_code":["61","21"],"billing_class":"professional","payments":[{"allowed_amount":378.40,"providers":[{"billed_charge":1220.00,"npi":[1194259796]}]},{"allowed_amount":454.08,"providers":[{"billed_charge":1464.00,"npi":[1194259796]}]}]},{"tin":{"type":"ein","value":"721597863"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":378.40,"providers":[{"billed_charge":1105.00,"npi":[1386931004]}]}]},{"tin":{"type":"ein","value":"203710982"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":2875.84,"providers":[{"billed_charge":5700.00,"npi":[1417954280]}]}]},{"tin":{"type":"ein","value":"880481331"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":298.08,"providers":[{"billed_charge":888.00,"npi":[1073689048]}]}]}]},{"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":"886000720"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":154.64,"providers":[{"billed_charge":482.56,"npi":[1487776050]}]}]},{"tin":{"type":"ein","value":"880125707"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":355.60,"providers":[{"billed_charge":1642.46,"npi":[1235232562]}]}]},{"tin":{"type":"ein","value":"880175774"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":2057.94,"providers":[{"billed_charge":6241.25,"npi":[1841257391]}]}]},{"tin":{"type":"ein","value":"271466450"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":2771.62,"providers":[{"billed_charge":8615.98,"npi":[1881915155]}]}]}]},{"name":"AMB SVC ALS ER TRNSPRT LVL1","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A0427","description":"AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS 1 - EMERGENCY)","allowed_amounts":[{"tin":{"type":"ein","value":"886000720"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1405.72,"providers":[{"billed_charge":2624.68,"npi":[1487776050]}]}]},{"tin":{"type":"ein","value":"880175774"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":6325.74,"providers":[{"billed_charge":18900.00,"npi":[1841257391]}]}]},{"tin":{"type":"ein","value":"271466450"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":4217.16,"providers":[{"billed_charge":7874.04,"npi":[1881915155]}]}]}]},{"name":"INTENS CARD REHAB; W/WO ECG","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"G0422","description":"INTENSIVE CARDIAC REHABILITATION; WITH OR WITHOUT CONTINUOUS ECG MONITORING WITH EXERCISE, PER SESSI","allowed_amounts":[{"tin":{"type":"ein","value":"200562668"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":3515.37,"providers":[{"billed_charge":12294.24,"npi":[1639134828]}]}]}]},{"name":"FCE-FCE BEHAVRL CNSL OBESITY","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"G0447","description":"FACE-TO-FACE BEHAVIORAL COUNSELING FOR OBESITY, 15 MINUTES","allowed_amounts":[{"tin":{"type":"ein","value":"852058371"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":68.22,"providers":[{"billed_charge":171.27,"npi":[1093271132]}]}]}]},{"name":"HT; ENTERAL NUTRIT VIA PUMP;","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"S9342","description":"HOME THERAPY; ENTERAL NUTRITION VIA PUMP; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, C","allowed_amounts":[{"tin":{"type":"ein","value":"760215922"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":410.00,"providers":[{"billed_charge":9739.55,"npi":[1790734036]}]}]}]}]}