{"reporting_entity_name":"Centene Management Company LLC","reporting_entity_type":"Third Party Administrator","version":"1.0.0","last_updated_on":"2025-09-29","out_of_network":[{"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":4140.03,"providers":[{"billed_charge":13872.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":107.77,"providers":[{"billed_charge":690.00,"npi":[1457895336]}]},{"allowed_amount":2494.67,"providers":[{"billed_charge":12366.66,"npi":[1922542968]}]}]}]},{"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":69.27,"providers":[{"billed_charge":488.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":9.27,"providers":[{"billed_charge":29225.00,"npi":[1578007514]}]},{"allowed_amount":967.73,"providers":[{"billed_charge":76336.44,"npi":[1922542968]}]},{"allowed_amount":149.06,"providers":[{"billed_charge":4072.00,"npi":[1740724780]}]},{"allowed_amount":959.25,"providers":[{"billed_charge":85258.45,"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":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":31.55,"providers":[{"billed_charge":19284.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":211.16,"providers":[{"billed_charge":10999.00,"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":195.84,"providers":[{"billed_charge":21766.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":90.64,"providers":[{"billed_charge":7496.00,"npi":[1528101284]}]}]}]},{"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":822.63,"providers":[{"billed_charge":7237.00,"npi":[1770626426]}]}]}]},{"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":1.88,"providers":[{"billed_charge":26.25,"npi":[1234567893]}]}]}]},{"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":27103.88,"providers":[{"billed_charge":128166.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"743048428"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":7781.10,"providers":[{"billed_charge":92720.00,"npi":[1114576857]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":4067.82,"providers":[{"billed_charge":16883.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3334.32,"providers":[{"billed_charge":80563.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":6722.48,"providers":[{"billed_charge":28770.03,"npi":[1457895336]}]},{"allowed_amount":19385.26,"providers":[{"billed_charge":44685.31,"npi":[1922542968]}]}]}]},{"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":2634.45,"providers":[{"billed_charge":3921.08,"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":393.75,"providers":[{"billed_charge":6845.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"743048428"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":8.64,"providers":[{"billed_charge":865.18,"npi":[1114576857]}]}]},{"tin":{"type":"ein","value":"851644866"},"service_code":["21"],"billing_class":"institutional","payments":[{"allowed_amount":3390.93,"providers":[{"billed_charge":11303.10,"npi":[1417554528]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1.87,"providers":[{"billed_charge":208.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"946004062"},"service_code":["23","21"],"billing_class":"institutional","payments":[{"allowed_amount":512.25,"providers":[{"billed_charge":1707.50,"npi":[1538265780]}]},{"allowed_amount":191.25,"providers":[{"billed_charge":637.50,"npi":[1538265780]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":104.96,"providers":[{"billed_charge":4661.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"621600397"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":19.25,"providers":[{"billed_charge":137.50,"npi":[1407405145]}]}]}]},{"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":199.24,"providers":[{"billed_charge":2210.00,"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":668.04,"providers":[{"billed_charge":7410.00,"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":515.68,"providers":[{"billed_charge":5720.00,"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":644.60,"providers":[{"billed_charge":7150.00,"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":644.60,"providers":[{"billed_charge":9350.00,"npi":[1234567893]}]}]}]},{"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":984.48,"providers":[{"billed_charge":10920.00,"npi":[1234567893]}]}]}]},{"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":631.19,"providers":[{"billed_charge":5325.00,"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":4373.98,"providers":[{"billed_charge":8529.69,"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":409.20,"providers":[{"billed_charge":1100.00,"npi":[1205896248]}]}]},{"tin":{"type":"ein","value":"842069428"},"service_code":["60"],"billing_class":"professional","payments":[{"allowed_amount":100.00,"providers":[{"billed_charge":280.00,"npi":[1578552394]}]}]}]},{"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":342.94,"providers":[{"billed_charge":818.00,"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":924.15,"providers":[{"billed_charge":2070.00,"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":631.17,"providers":[{"billed_charge":1350.00,"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":1385.04,"providers":[{"billed_charge":3000.00,"npi":[1760950844]}]}]},{"tin":{"type":"ein","value":"901816028"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":623.28,"providers":[{"billed_charge":1500.00,"npi":[1891090718]}]}]},{"tin":{"type":"ein","value":"461482002"},"service_code":["11","02"],"billing_class":"professional","payments":[{"allowed_amount":727.16,"providers":[{"billed_charge":1400.00,"npi":[1215221957]}]},{"allowed_amount":934.92,"providers":[{"billed_charge":1800.00,"npi":[1215221957]}]}]},{"tin":{"type":"ein","value":"994244685"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1962.14,"providers":[{"billed_charge":2720.00,"npi":[1215384839]}]}]}]},{"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":364.52,"providers":[{"billed_charge":520.00,"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":30468.72,"providers":[{"billed_charge":31600.00,"npi":[1972311090]}]}]},{"tin":{"type":"ein","value":"954836285"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":747.26,"providers":[{"billed_charge":1457.00,"npi":[1053104356]}]}]}]},{"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":3361.10,"providers":[{"billed_charge":4560.00,"npi":[1164482147]}]}]},{"tin":{"type":"ein","value":"880321712"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":309.58,"providers":[{"billed_charge":430.00,"npi":[1528218765]}]}]},{"tin":{"type":"ein","value":"204477738"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":782.89,"providers":[{"billed_charge":2052.00,"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":528.80,"providers":[{"billed_charge":1336.00,"npi":[1316694037]}]},{"allowed_amount":132.20,"providers":[{"billed_charge":334.00,"npi":[1598380958]}]}]},{"tin":{"type":"ein","value":"822164388"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":1269.12,"providers":[{"billed_charge":3984.00,"npi":[1497302962]}]}]}]},{"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":"845008287"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":298.08,"providers":[{"billed_charge":540.00,"npi":[1871857953]}]}]},{"tin":{"type":"ein","value":"203710982"},"service_code":["61","21"],"billing_class":"professional","payments":[{"allowed_amount":908.16,"providers":[{"billed_charge":1800.00,"npi":[1417954280]}]},{"allowed_amount":2119.04,"providers":[{"billed_charge":4200.00,"npi":[1417954280]}]}]},{"tin":{"type":"ein","value":"880481331"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":3278.88,"providers":[{"billed_charge":9768.00,"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":441.45,"providers":[{"billed_charge":1521.92,"npi":[1487776050]}]}]},{"tin":{"type":"ein","value":"880125707"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":657.08,"providers":[{"billed_charge":4166.62,"npi":[1235232562]}]}]},{"tin":{"type":"ein","value":"880175774"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1909.27,"providers":[{"billed_charge":5781.25,"npi":[1841257391]}]}]},{"tin":{"type":"ein","value":"271466450"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":3653.65,"providers":[{"billed_charge":10367.64,"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":3514.30,"providers":[{"billed_charge":6561.70,"npi":[1487776050]}]}]},{"tin":{"type":"ein","value":"880125707"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1900.19,"providers":[{"billed_charge":6561.70,"npi":[1235232562]}]}]},{"tin":{"type":"ein","value":"880175774"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":4920.02,"providers":[{"billed_charge":14700.00,"npi":[1841257391]}]}]},{"tin":{"type":"ein","value":"271466450"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":6113.26,"providers":[{"billed_charge":10498.72,"npi":[1881915155]}]}]}]},{"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":1010.00,"providers":[{"billed_charge":23992.55,"npi":[1790734036]}]}]}]},{"name":"INTNSVE OP PSYC SVC PER DIEM","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"S9480","description":"INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEM","allowed_amounts":[{"tin":{"type":"ein","value":"990542920"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":21000.00,"providers":[{"billed_charge":52500.00,"npi":[1194587576]}]}]}]}]}