{"reporting_entity_name":"Centene Management Company LLC","reporting_entity_type":"Third Party Administrator","version":"1.0.0","last_updated_on":"2025-10-28","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":3263.64,"providers":[{"billed_charge":16454.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":1920.26,"providers":[{"billed_charge":7635.31,"npi":[1922542968]}]},{"allowed_amount":215.54,"providers":[{"billed_charge":1380.00,"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":74.65,"providers":[{"billed_charge":6391.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":810.19,"providers":[{"billed_charge":110539.34,"npi":[1457895336]}]},{"allowed_amount":186.14,"providers":[{"billed_charge":49193.95,"npi":[1578007514]}]},{"allowed_amount":958.46,"providers":[{"billed_charge":68675.81,"npi":[1922542968]}]}]}]},{"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":27004.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":234.94,"providers":[{"billed_charge":10907.00,"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":139.96,"providers":[{"billed_charge":19292.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":40.28,"providers":[{"billed_charge":4365.00,"npi":[1528101284]}]}]}]},{"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":564.57,"providers":[{"billed_charge":33183.00,"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":39906.80,"providers":[{"billed_charge":173930.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"743048428"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":5765.51,"providers":[{"billed_charge":74221.00,"npi":[1114576857]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":2962.58,"providers":[{"billed_charge":12627.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":3778.48,"providers":[{"billed_charge":88534.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"364827272"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":9064.88,"providers":[{"billed_charge":40704.31,"npi":[1922542968]}]},{"allowed_amount":4505.24,"providers":[{"billed_charge":19198.15,"npi":[1457895336]}]},{"allowed_amount":646.72,"providers":[{"billed_charge":2670.00,"npi":[1578007514]}]}]}]},{"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":2498.00,"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":9.54,"providers":[{"billed_charge":8296.00,"npi":[1770626426]}]}]},{"tin":{"type":"ein","value":"743048428"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":38.78,"providers":[{"billed_charge":277.00,"npi":[1184476145]}]},{"allowed_amount":1.35,"providers":[{"billed_charge":897.27,"npi":[1114576857]}]}]},{"tin":{"type":"ein","value":"851644866"},"service_code":["21"],"billing_class":"institutional","payments":[{"allowed_amount":6588.97,"providers":[{"billed_charge":21963.24,"npi":[1417554528]}]}]},{"tin":{"type":"ein","value":"383730230"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":8.42,"providers":[{"billed_charge":3393.00,"npi":[1528101284]}]}]},{"tin":{"type":"ein","value":"946004062"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":114.45,"providers":[{"billed_charge":170.00,"npi":[1801957667]}]}]},{"tin":{"type":"ein","value":"811112022"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":134.69,"providers":[{"billed_charge":4792.00,"npi":[1285490292]}]}]},{"tin":{"type":"ein","value":"621600397"},"service_code":["23"],"billing_class":"institutional","payments":[{"allowed_amount":86.66,"providers":[{"billed_charge":619.00,"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":128.92,"providers":[{"billed_charge":1430.00,"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":539.12,"providers":[{"billed_charge":5980.00,"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":421.92,"providers":[{"billed_charge":4680.00,"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":539.12,"providers":[{"billed_charge":5980.00,"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":"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":773.52,"providers":[{"billed_charge":8580.00,"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":595.63,"providers":[{"billed_charge":5025.00,"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":3701.06,"providers":[{"billed_charge":7257.44,"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":"842069428"},"service_code":["60"],"billing_class":"professional","payments":[{"allowed_amount":340.00,"providers":[{"billed_charge":952.00,"npi":[1578552394]}]}]}]},{"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":985.76,"providers":[{"billed_charge":2208.00,"npi":[1497302962]}]}]},{"tin":{"type":"ein","value":"462967514"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":61.61,"providers":[{"billed_charge":95.00,"npi":[1427593136]}]},{"allowed_amount":677.71,"providers":[{"billed_charge":1045.00,"npi":[1710490479]}]}]}]},{"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","02"],"billing_class":"professional","payments":[{"allowed_amount":70.13,"providers":[{"billed_charge":150.00,"npi":[1215221957]}]},{"allowed_amount":1192.21,"providers":[{"billed_charge":2550.00,"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","10"],"billing_class":"professional","payments":[{"allowed_amount":1038.78,"providers":[{"billed_charge":2250.00,"npi":[1760950844]}]},{"allowed_amount":115.42,"providers":[{"billed_charge":250.00,"npi":[1760950844]}]}]},{"tin":{"type":"ein","value":"901816028"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1350.44,"providers":[{"billed_charge":3250.00,"npi":[1891090718]}]}]},{"tin":{"type":"ein","value":"383889285"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":115.42,"providers":[{"billed_charge":300.00,"npi":[1124840012]}]}]},{"tin":{"type":"ein","value":"454429023"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":692.52,"providers":[{"billed_charge":1200.00,"npi":[1114731981]}]}]},{"tin":{"type":"ein","value":"814113791"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":461.68,"providers":[{"billed_charge":1342.62,"npi":[1598135279]}]}]},{"tin":{"type":"ein","value":"471013467"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":484.76,"providers":[{"billed_charge":1060.00,"npi":[1437405545]}]}]},{"tin":{"type":"ein","value":"461482002"},"service_code":["11","02"],"billing_class":"professional","payments":[{"allowed_amount":727.16,"providers":[{"billed_charge":1400.00,"npi":[1215221957]}]}]},{"tin":{"type":"ein","value":"994244685"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":2885.50,"providers":[{"billed_charge":4000.00,"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":420.60,"providers":[{"billed_charge":600.00,"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":32397.12,"providers":[{"billed_charge":33600.00,"npi":[1972311090]}]}]},{"tin":{"type":"ein","value":"954836285"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":2796.21,"providers":[{"billed_charge":5452.00,"npi":[1053104356]}]},{"allowed_amount":1012.41,"providers":[{"billed_charge":1974.00,"npi":[1467347914]}]}]}]},{"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":2476.60,"providers":[{"billed_charge":3360.00,"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","02"],"billing_class":"professional","payments":[{"allowed_amount":88.45,"providers":[{"billed_charge":228.00,"npi":[1588602957]}]},{"allowed_amount":3670.68,"providers":[{"billed_charge":9576.00,"npi":[1588602957]}]},{"allowed_amount":796.05,"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":396.60,"providers":[{"billed_charge":1002.00,"npi":[1568008878]}]},{"allowed_amount":925.40,"providers":[{"billed_charge":2338.00,"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":1480.64,"providers":[{"billed_charge":4648.00,"npi":[1497302962]}]}]},{"tin":{"type":"ein","value":"204477738"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1493.04,"providers":[{"billed_charge":3996.00,"npi":[1588602957]}]}]},{"tin":{"type":"ein","value":"462967514"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":740.32,"providers":[{"billed_charge":1400.00,"npi":[1710490479]}]}]}]},{"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":1437.92,"providers":[{"billed_charge":2850.00,"npi":[1417954280]}]},{"allowed_amount":983.84,"providers":[{"billed_charge":1950.00,"npi":[1417954280]}]}]},{"tin":{"type":"ein","value":"412211089"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":745.20,"providers":[{"billed_charge":1890.00,"npi":[1275511263]}]}]},{"tin":{"type":"ein","value":"880481331"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":2384.64,"providers":[{"billed_charge":7104.00,"npi":[1073689048]}]}]}]},{"name":"PREV VISIT EST AGE 40-64","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99396","description":"PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCL AN AGE","allowed_amounts":[{"tin":{"type":"ein","value":"204477738"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":601.60,"providers":[{"billed_charge":1510.00,"npi":[1588602957]}]}]}]},{"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":300.02,"providers":[{"billed_charge":965.12,"npi":[1487776050]}]}]},{"tin":{"type":"ein","value":"880125707"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":582.35,"providers":[{"billed_charge":3823.36,"npi":[1235232562]}]}]},{"tin":{"type":"ein","value":"880175774"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1008.50,"providers":[{"billed_charge":3062.50,"npi":[1841257391]}]}]},{"tin":{"type":"ein","value":"271466450"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":3744.49,"providers":[{"billed_charge":10211.71,"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":2740.27,"providers":[{"billed_charge":6561.70,"npi":[1487776050]}]}]},{"tin":{"type":"ein","value":"880125707"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":2183.01,"providers":[{"billed_charge":7874.04,"npi":[1235232562]}]}]},{"tin":{"type":"ein","value":"880175774"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1147.71,"providers":[{"billed_charge":4200.00,"npi":[1841257391]}]}]},{"tin":{"type":"ein","value":"271466450"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":7845.90,"providers":[{"billed_charge":13123.40,"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":1757.68,"providers":[{"billed_charge":6147.12,"npi":[1639134828]}]}]}]},{"name":"ANL ALCHL MISUSE SCREN 15MIM","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"G0442","description":"ANNUAL ALCOHOL MISUSE SCREENING, 15 MINUTES","allowed_amounts":[{"tin":{"type":"ein","value":"204477738"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":375.98,"providers":[{"billed_charge":814.00,"npi":[1588602957]}]}]}]},{"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":33000.00,"providers":[{"billed_charge":82500.00,"npi":[1194587576]}]}]}]}]}