{"reporting_entity_name":"Centene Management Company LLC","reporting_entity_type":"Third Party Administrator","version":"1.0.0","last_updated_on":"2025-12-30","out_of_network":[{"name":"ANES LWR INTST SCR COLSC","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"00812","description":"ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES, ENDOSCOPE INTRODUCED DISTAL TO DUODENUM; SCRE","allowed_amounts":[{"tin":{"type":"ein","value":"861908119"},"service_code":["24","21"],"billing_class":"professional","payments":[{"allowed_amount":320.30,"providers":[{"billed_charge":6300.00,"npi":[1619633898]}]},{"allowed_amount":133.46,"providers":[{"billed_charge":2700.00,"npi":[1619633898]}]}]},{"tin":{"type":"ein","value":"204996308"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":261.74,"providers":[{"billed_charge":10000.00,"npi":[1053351973]}]}]}]},{"name":"ASSAY OF MAGNESIUM","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"301","description":"MAGNESIUM","allowed_amounts":[{"tin":{"type":"ein","value":"221487307"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":16.00,"providers":[{"billed_charge":16.00,"npi":[1013912633]}]}]}]},{"name":"OFFICE/OUTPATIENT VISIT EST","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"519","description":"OFFICE OR OTH OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH RE","allowed_amounts":[{"tin":{"type":"ein","value":"830719122"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":105.18,"providers":[{"billed_charge":100.00,"npi":[1275103384]}]},{"allowed_amount":22.68,"providers":[{"billed_charge":50.00,"npi":[1275103384]}]},{"allowed_amount":693.60,"providers":[{"billed_charge":750.00,"npi":[1275103384]}]}]}]},{"name":"HZV VACCINE LIVE SUBQ","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"519","description":"ZOSTER (SHINGLES) VACCINE (HZV), LIVE, FOR SUBCUTANEOUS INJECTION","allowed_amounts":[{"tin":{"type":"ein","value":"830719122"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":105.18,"providers":[{"billed_charge":100.00,"npi":[1275103384]}]},{"allowed_amount":22.68,"providers":[{"billed_charge":50.00,"npi":[1275103384]}]},{"allowed_amount":693.60,"providers":[{"billed_charge":750.00,"npi":[1275103384]}]}]}]},{"name":"MED SERV EVE/WKEND/HOLIDAY","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"519","description":"SERVICE(S) PROVIDED IN THE OFFICE DURING REGULARLY SCHEDULED EVENING, WEEKEND, OR HOLIDAY OFFICE HOU","allowed_amounts":[{"tin":{"type":"ein","value":"830719122"},"service_code":["50"],"billing_class":"institutional","payments":[{"allowed_amount":105.18,"providers":[{"billed_charge":100.00,"npi":[1275103384]}]},{"allowed_amount":22.68,"providers":[{"billed_charge":50.00,"npi":[1275103384]}]},{"allowed_amount":693.60,"providers":[{"billed_charge":750.00,"npi":[1275103384]}]}]}]},{"name":"GRND MLGE PER STATUTE MILE","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"540","description":"GROUND MILEAGE, PER STATUTE MILE","allowed_amounts":[{"tin":{"type":"ein","value":"133957095"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":7416.22,"providers":[{"billed_charge":9324.88,"npi":[1174628473]}]},{"allowed_amount":2555.00,"providers":[{"billed_charge":9559.12,"npi":[1174628473]}]},{"allowed_amount":230.57,"providers":[{"billed_charge":452.97,"npi":[1174628473]}]}]}]},{"name":"SPECIALTY CARE TRANSPORT","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"540","description":"SPECIALTY CARE TRANSPORT (SCT)","allowed_amounts":[{"tin":{"type":"ein","value":"133957095"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":7416.22,"providers":[{"billed_charge":9324.88,"npi":[1174628473]}]},{"allowed_amount":2555.00,"providers":[{"billed_charge":9559.12,"npi":[1174628473]}]},{"allowed_amount":230.57,"providers":[{"billed_charge":452.97,"npi":[1174628473]}]}]}]},{"name":"AMB SERVICE BLS EMERGENCY TR","billing_code_type":"RC","billing_code_type_version":"2022","billing_code":"540","description":"AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS, EMERGENCY)","allowed_amounts":[{"tin":{"type":"ein","value":"133957095"},"service_code":["22"],"billing_class":"institutional","payments":[{"allowed_amount":7416.22,"providers":[{"billed_charge":9324.88,"npi":[1174628473]}]},{"allowed_amount":2555.00,"providers":[{"billed_charge":9559.12,"npi":[1174628473]}]},{"allowed_amount":230.57,"providers":[{"billed_charge":452.97,"npi":[1174628473]}]}]}]},{"name":"CT HEAD/BRAIN W/O DYE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"70450","description":"COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","19","21"],"billing_class":"professional","payments":[{"allowed_amount":47.84,"providers":[{"billed_charge":637.00,"npi":[1255962783]}]},{"allowed_amount":50.36,"providers":[{"billed_charge":637.00,"npi":[1255962783]}]},{"allowed_amount":4398.26,"providers":[{"billed_charge":52234.00,"npi":[1255962783]}]},{"allowed_amount":1246.40,"providers":[{"billed_charge":15925.00,"npi":[1255962783]}]}]}]},{"name":"CT ANGIOGRAPHY HEAD","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"70496","description":"COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":1300.39,"providers":[{"billed_charge":14148.00,"npi":[1255962783]}]}]}]},{"name":"CT ANGIOGRAPHY NECK","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"70498","description":"COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["23","21"],"billing_class":"professional","payments":[{"allowed_amount":1221.88,"providers":[{"billed_charge":15609.00,"npi":[1255962783]}]},{"allowed_amount":309.39,"providers":[{"billed_charge":4257.00,"npi":[1255962783]}]}]}]},{"name":"MRI BRAIN STEM W/O DYE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"70551","description":"MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","21"],"billing_class":"professional","payments":[{"allowed_amount":519.20,"providers":[{"billed_charge":6258.00,"npi":[1255962783]}]},{"allowed_amount":170.15,"providers":[{"billed_charge":2086.00,"npi":[1255962783]}]},{"allowed_amount":189.70,"providers":[{"billed_charge":2086.00,"npi":[1255962783]}]}]}]},{"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":"844522008"},"service_code":["22","23","21"],"billing_class":"professional","payments":[{"allowed_amount":87.76,"providers":[{"billed_charge":1408.00,"npi":[1255962783]}]},{"allowed_amount":1415.13,"providers":[{"billed_charge":22704.00,"npi":[1255962783]}]},{"allowed_amount":2133.68,"providers":[{"billed_charge":31504.00,"npi":[1255962783]}]}]}]},{"name":"X-RAY EXAM CHEST 2 VIEWS","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"71046","description":"RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","20","21"],"billing_class":"professional","payments":[{"allowed_amount":91.00,"providers":[{"billed_charge":1372.00,"npi":[1255962783]}]},{"allowed_amount":13.00,"providers":[{"billed_charge":196.00,"npi":[1255962783]}]},{"allowed_amount":520.00,"providers":[{"billed_charge":7840.00,"npi":[1255962783]}]},{"allowed_amount":494.55,"providers":[{"billed_charge":6686.38,"npi":[1255962783]}]}]}]},{"name":"CT THORAX W/O DYE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"71250","description":"COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23"],"billing_class":"professional","payments":[{"allowed_amount":65.83,"providers":[{"billed_charge":731.00,"npi":[1255962783]}]},{"allowed_amount":127.48,"providers":[{"billed_charge":1462.00,"npi":[1255962783]}]}]}]},{"name":"CT ANGIOGRAPHY CHEST","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"71275","description":"COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTR","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["23","21"],"billing_class":"professional","payments":[{"allowed_amount":1858.88,"providers":[{"billed_charge":26640.00,"npi":[1255962783]}]},{"allowed_amount":313.85,"providers":[{"billed_charge":4995.00,"npi":[1255962783]}]}]}]},{"name":"X-RAY EXAM L-S SPINE 2/3 VWS","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"72100","description":"RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; 2 OR 3 VIEWS","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","19"],"billing_class":"professional","payments":[{"allowed_amount":40.32,"providers":[{"billed_charge":573.00,"npi":[1255962783]}]},{"allowed_amount":13.44,"providers":[{"billed_charge":191.00,"npi":[1255962783]}]}]}]},{"name":"CT NECK SPINE W/O DYE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"72125","description":"COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":636.30,"providers":[{"billed_charge":7220.00,"npi":[1255962783]}]}]}]},{"name":"X-RAY EXAM OF SHOULDER","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"73030","description":"RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 2 VIEWS","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","19","20"],"billing_class":"professional","payments":[{"allowed_amount":37.20,"providers":[{"billed_charge":459.00,"npi":[1255962783]}]},{"allowed_amount":11.41,"providers":[{"billed_charge":153.00,"npi":[1255962783]}]},{"allowed_amount":79.87,"providers":[{"billed_charge":1071.00,"npi":[1255962783]}]}]}]},{"name":"X-RAY EXAM OF KNEE 3","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"73562","description":"RADIOLOGIC EXAMINATION, KNEE; 3 VIEWS","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","19"],"billing_class":"professional","payments":[{"allowed_amount":22.82,"providers":[{"billed_charge":280.00,"npi":[1255962783]}]},{"allowed_amount":12.40,"providers":[{"billed_charge":140.00,"npi":[1255962783]}]},{"allowed_amount":45.64,"providers":[{"billed_charge":560.00,"npi":[1255962783]}]}]}]},{"name":"X-RAY EXAM OF ANKLE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"73610","description":"RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF 3 VIEWS","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23"],"billing_class":"professional","payments":[{"allowed_amount":42.28,"providers":[{"billed_charge":536.00,"npi":[1255962783]}]},{"allowed_amount":36.76,"providers":[{"billed_charge":536.00,"npi":[1255962783]}]}]}]},{"name":"X-RAY EXAM OF FOOT","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"73630","description":"RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF 3 VIEWS","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","19","20"],"billing_class":"professional","payments":[{"allowed_amount":30.36,"providers":[{"billed_charge":381.00,"npi":[1255962783]}]},{"allowed_amount":10.12,"providers":[{"billed_charge":127.00,"npi":[1255962783]}]},{"allowed_amount":121.00,"providers":[{"billed_charge":1397.00,"npi":[1255962783]}]}]}]},{"name":"X-RAY EXAM ABDOMEN 1 VIEW","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"74018","description":"RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","21"],"billing_class":"professional","payments":[{"allowed_amount":23.84,"providers":[{"billed_charge":322.00,"npi":[1255962783]}]},{"allowed_amount":43.88,"providers":[{"billed_charge":644.00,"npi":[1255962783]}]},{"allowed_amount":54.85,"providers":[{"billed_charge":805.00,"npi":[1255962783]}]}]}]},{"name":"CT ABD & PELVIS W/O CONTRAST","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"74176","description":"COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","19","21"],"billing_class":"professional","payments":[{"allowed_amount":102.74,"providers":[{"billed_charge":1617.00,"npi":[1255962783]}]},{"allowed_amount":2233.60,"providers":[{"billed_charge":32340.00,"npi":[1255962783]}]},{"allowed_amount":616.44,"providers":[{"billed_charge":9702.00,"npi":[1255962783]}]},{"allowed_amount":308.22,"providers":[{"billed_charge":4851.00,"npi":[1255962783]}]}]}]},{"name":"CT ABD & PELV W/CONTRAST","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"74177","description":"COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","19","21"],"billing_class":"professional","payments":[{"allowed_amount":9084.96,"providers":[{"billed_charge":130284.00,"npi":[1255962783]}]},{"allowed_amount":760.76,"providers":[{"billed_charge":11844.00,"npi":[1255962783]}]},{"allowed_amount":108.68,"providers":[{"billed_charge":1692.00,"npi":[1255962783]}]},{"allowed_amount":1086.80,"providers":[{"billed_charge":16920.00,"npi":[1255962783]}]}]}]},{"name":"ULTRASOUND BREAST COMPLETE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"76641","description":"ULTRASOUND, BREAST, UNILATERAL, REAL TIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED;","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","19"],"billing_class":"professional","payments":[{"allowed_amount":1673.88,"providers":[{"billed_charge":22607.00,"npi":[1255962783]}]},{"allowed_amount":1025.36,"providers":[{"billed_charge":13949.00,"npi":[1255962783]}]}]}]},{"name":"ULTRASOUND BREAST LIMITED","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"76642","description":"ULTRASOUND, BREAST, UNILATERAL, REAL TIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED;","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","19"],"billing_class":"professional","payments":[{"allowed_amount":229.26,"providers":[{"billed_charge":2820.00,"npi":[1255962783]}]},{"allowed_amount":294.76,"providers":[{"billed_charge":3760.00,"npi":[1255962783]}]}]}]},{"name":"ECHO EXAM OF ABDOMEN","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"76705","description":"ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","21"],"billing_class":"professional","payments":[{"allowed_amount":413.21,"providers":[{"billed_charge":5082.00,"npi":[1255962783]}]},{"allowed_amount":69.76,"providers":[{"billed_charge":924.00,"npi":[1255962783]}]},{"allowed_amount":34.88,"providers":[{"billed_charge":462.00,"npi":[1255962783]}]}]}]},{"name":"OB US LIMITED FETUS(S)","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"76815","description":"ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLAC","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","21"],"billing_class":"professional","payments":[{"allowed_amount":115.77,"providers":[{"billed_charge":1305.00,"npi":[1255962783]}]},{"allowed_amount":38.59,"providers":[{"billed_charge":435.00,"npi":[1255962783]}]},{"allowed_amount":41.95,"providers":[{"billed_charge":435.00,"npi":[1255962783]}]}]}]},{"name":"TRANSVAGINAL US, OBSTETRIC","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"76817","description":"ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":44.34,"providers":[{"billed_charge":608.00,"npi":[1255962783]}]}]}]},{"name":"TRANSVAGINAL US, NON-OB","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"76830","description":"ULTRASOUND, TRANSVAGINAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","23","19"],"billing_class":"professional","payments":[{"allowed_amount":369.72,"providers":[{"billed_charge":4509.00,"npi":[1255962783]}]},{"allowed_amount":41.08,"providers":[{"billed_charge":501.00,"npi":[1255962783]}]},{"allowed_amount":133.95,"providers":[{"billed_charge":1503.00,"npi":[1255962783]}]}]}]},{"name":"US EXAM, PELVIC, COMPLETE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"76856","description":"ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":68.44,"providers":[{"billed_charge":928.00,"npi":[1255962783]}]}]}]},{"name":"BREAST TOMOSYNTHESIS BI","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"77062","description":"DIGITAL BREAST TOMOSYNTHESIS; BILATERAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":106.65,"providers":[{"billed_charge":852.00,"npi":[1255962783]}]}]}]},{"name":"BREAST TOMOSYNTHESIS BI","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"77063","description":"SCREENING DIGITAL BREAST TOMOSYNTHESIS, BILATERAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY P","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","19"],"billing_class":"professional","payments":[{"allowed_amount":985.87,"providers":[{"billed_charge":5572.00,"npi":[1255962783]}]},{"allowed_amount":2168.20,"providers":[{"billed_charge":12338.00,"npi":[1255962783]}]}]}]},{"name":"DX MAMMO INCL CAD UNI","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"77065","description":"DIAGNOSTIC MAMMOGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED; UNILATERAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":47.87,"providers":[{"billed_charge":319.00,"npi":[1255962783]}]}]}]},{"name":"DX MAMMO INCL CAD BI","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"77066","description":"DIAGNOSTIC MAMMOGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED; BILATERAL","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":175.62,"providers":[{"billed_charge":1203.00,"npi":[1255962783]}]}]}]},{"name":"SCR MAMMO BI INCL CAD","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"77067","description":"SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["22","19"],"billing_class":"professional","payments":[{"allowed_amount":1227.15,"providers":[{"billed_charge":7965.00,"npi":[1255962783]}]},{"allowed_amount":2886.08,"providers":[{"billed_charge":18880.00,"npi":[1255962783]}]}]}]},{"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":"843016042"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":24.28,"providers":[{"billed_charge":280.00,"npi":[1598315574]}]}]}]},{"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":"133457651"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":77.28,"providers":[{"billed_charge":180.00,"npi":[1255409553]}]}]}]},{"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":"133457651"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":8.94,"providers":[{"billed_charge":20.00,"npi":[1255409553]}]}]}]},{"name":"TISSUE EXAM BY PATHOLOGIST","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"88305","description":"LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ABORTION - SPONTANEOUS/MISSED ARTER","allowed_amounts":[{"tin":{"type":"ein","value":"831187935"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":197.34,"providers":[{"billed_charge":525.00,"npi":[1720051907]}]}]}]},{"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":"460751479"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":611.76,"providers":[{"billed_charge":1500.00,"npi":[1437334190]}]}]},{"tin":{"type":"ein","value":"134137499"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":4250.00,"providers":[{"billed_charge":4250.00,"npi":[1578703195]}]}]}]},{"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":"90729290"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":150.00,"providers":[{"billed_charge":150.00,"npi":[1578747523]}]}]},{"tin":{"type":"ein","value":"834140142"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":13000.00,"providers":[{"billed_charge":13000.00,"npi":[1326393919]}]}]},{"tin":{"type":"ein","value":"465223892"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1768.62,"providers":[{"billed_charge":1975.00,"npi":[1649694506]}]}]},{"tin":{"type":"ein","value":"143805789"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":2250.00,"providers":[{"billed_charge":2250.00,"npi":[1336652155]}]}]}]},{"name":"TCRANIAL MAGN STIM TX DELI","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"90868","description":"THERAPEUTIC REPETITIVE TRANSCRANIAL MAGNETIC STIMULATION (TMS) TREATMENT; SUBSEQUENT DELIVERY AND MA","allowed_amounts":[{"tin":{"type":"ein","value":"863089181"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":2003.75,"providers":[{"billed_charge":5600.00,"npi":[1578516969]}]},{"allowed_amount":5347.02,"providers":[{"billed_charge":14700.00,"npi":[1194399048]}]}]},{"tin":{"type":"ein","value":"822894814"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":2413.36,"providers":[{"billed_charge":4000.00,"npi":[1194769976]}]}]}]},{"name":"ELECTROCARDIOGRAM REPORT","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"93010","description":"ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY","allowed_amounts":[{"tin":{"type":"ein","value":"112558775"},"service_code":["23","21"],"billing_class":"professional","payments":[{"allowed_amount":40.48,"providers":[{"billed_charge":160.00,"npi":[1013932250]}]},{"allowed_amount":88.00,"providers":[{"billed_charge":320.00,"npi":[1013932250]}]}]}]},{"name":"EXTREMITY STUDY","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"93970","description":"DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILA","allowed_amounts":[{"tin":{"type":"ein","value":"844522008"},"service_code":["23","21"],"billing_class":"professional","payments":[{"allowed_amount":88.40,"providers":[{"billed_charge":1306.00,"npi":[1255962783]}]},{"allowed_amount":203.30,"providers":[{"billed_charge":3265.00,"npi":[1255962783]}]}]}]},{"name":"THERAPEUTIC EXERCISES","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"97110","description":"THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH A","allowed_amounts":[{"tin":{"type":"ein","value":"873599459"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":377.30,"providers":[{"billed_charge":758.40,"npi":[1972257541]}]}]},{"tin":{"type":"ein","value":"113322995"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":226.38,"providers":[{"billed_charge":600.00,"npi":[1093944373]}]}]}]},{"name":"NEUROMUSCULAR REEDUCATION","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"97112","description":"THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALA","allowed_amounts":[{"tin":{"type":"ein","value":"873599459"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":503.28,"providers":[{"billed_charge":951.60,"npi":[1972257541]}]}]},{"tin":{"type":"ein","value":"113322995"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":167.76,"providers":[{"billed_charge":400.00,"npi":[1093944373]}]}]}]},{"name":"MANUAL THERAPY 1/> REGIONS","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"97140","description":"MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTIO","allowed_amounts":[{"tin":{"type":"ein","value":"873599459"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":427.20,"providers":[{"billed_charge":900.00,"npi":[1972257541]}]}]},{"tin":{"type":"ein","value":"113322995"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":142.40,"providers":[{"billed_charge":400.00,"npi":[1093944373]}]}]}]},{"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":"813278370"},"service_code":["99"],"billing_class":"professional","payments":[{"allowed_amount":7166.40,"providers":[{"billed_charge":37500.00,"npi":[1043769466]}]}]},{"tin":{"type":"ein","value":"824459571"},"service_code":["11","12"],"billing_class":"professional","payments":[{"allowed_amount":165306.20,"providers":[{"billed_charge":170449.00,"npi":[1043710882]}]},{"allowed_amount":61600.30,"providers":[{"billed_charge":65208.00,"npi":[1043710882]}]}]},{"tin":{"type":"ein","value":"813535131"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":206050.00,"providers":[{"billed_charge":1648400.00,"npi":[1427502939]}]}]},{"tin":{"type":"ein","value":"470986503"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":1109.76,"providers":[{"billed_charge":5040.00,"npi":[1295148146]}]}]}]},{"name":"GRP ADAPT BHV TX BY TECH","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"97154","description":"GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN","allowed_amounts":[{"tin":{"type":"ein","value":"824459571"},"service_code":["11","12"],"billing_class":"professional","payments":[{"allowed_amount":1085.68,"providers":[{"billed_charge":6232.00,"npi":[1043710882]}]},{"allowed_amount":158.88,"providers":[{"billed_charge":912.00,"npi":[1043710882]}]}]}]},{"name":"ADAPT BEHAVIOR TX PHYS/QHP","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"97155","description":"ADAPT BHV TX PRTCL MODIFICAJ PHYS/QHP EA 15 MIN","allowed_amounts":[{"tin":{"type":"ein","value":"824459571"},"service_code":["11","12","02","10"],"billing_class":"professional","payments":[{"allowed_amount":4930.56,"providers":[{"billed_charge":6656.00,"npi":[1043710882]}]},{"allowed_amount":1926.00,"providers":[{"billed_charge":2600.00,"npi":[1043710882]}]},{"allowed_amount":3235.68,"providers":[{"billed_charge":4368.00,"npi":[1043710882]}]},{"allowed_amount":15635.26,"providers":[{"billed_charge":21034.00,"npi":[1043710882]}]}]},{"tin":{"type":"ein","value":"813535131"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":15675.00,"providers":[{"billed_charge":125400.00,"npi":[1427502939]}]}]}]},{"name":"FAM ADAPT BHV TX GDN PHY/QHP","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"97156","description":"FAMILY ADAPT BHV TX GDN PHYS/QHP EA 15 MIN","allowed_amounts":[{"tin":{"type":"ein","value":"824459571"},"service_code":["11","12","02","10"],"billing_class":"professional","payments":[{"allowed_amount":2349.72,"providers":[{"billed_charge":3172.00,"npi":[1043710882]}]},{"allowed_amount":154.08,"providers":[{"billed_charge":208.00,"npi":[1043710882]}]},{"allowed_amount":8551.44,"providers":[{"billed_charge":11544.00,"npi":[1043710882]}]},{"allowed_amount":8905.82,"providers":[{"billed_charge":11986.00,"npi":[1043710882]}]}]},{"tin":{"type":"ein","value":"813535131"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":11175.00,"providers":[{"billed_charge":89400.00,"npi":[1427502939]}]}]}]},{"name":"THERAPEUTIC ACTIVITIES","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"97530","description":"THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT (USE OF DYNAMIC ACTIVITIES TO IMPROVE FU","allowed_amounts":[{"tin":{"type":"ein","value":"113538970"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":8613.22,"providers":[{"billed_charge":9400.00,"npi":[1134634843]}]}]},{"tin":{"type":"ein","value":"873599459"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":549.84,"providers":[{"billed_charge":975.84,"npi":[1972257541]}]}]},{"tin":{"type":"ein","value":"464893551"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":17437.69,"providers":[{"billed_charge":42682.08,"npi":[1760807093]}]}]},{"tin":{"type":"ein","value":"141834123"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":387.92,"providers":[{"billed_charge":405.00,"npi":[1205830973]}]}]},{"tin":{"type":"ein","value":"113322995"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1420.27,"providers":[{"billed_charge":3050.00,"npi":[1497034748]}]}]},{"tin":{"type":"ein","value":"882919668"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":549.78,"providers":[{"billed_charge":900.00,"npi":[1861905978]}]}]}]},{"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":"133457651"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":167.07,"providers":[{"billed_charge":190.00,"npi":[1255409553]}]}]}]},{"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":"460873654"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":1773.80,"providers":[{"billed_charge":9158.80,"npi":[1295975704]}]}]},{"tin":{"type":"ein","value":"274384326"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":403.20,"providers":[{"billed_charge":1288.00,"npi":[1821169210]}]}]},{"tin":{"type":"ein","value":"203317668"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":705.60,"providers":[{"billed_charge":2450.00,"npi":[1225136591]}]}]}]},{"name":"SUBSEQUENT HOSPITAL CARE","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99233","description":"SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT","allowed_amounts":[{"tin":{"type":"ein","value":"201083852"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":299.14,"providers":[{"billed_charge":1700.00,"npi":[1497735153]}]}]}]},{"name":"EMERGENCY DEPT VISIT","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99284","description":"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KE","allowed_amounts":[{"tin":{"type":"ein","value":"474961193"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":1848.66,"providers":[{"billed_charge":10296.00,"npi":[1922460542]}]}]}]},{"name":"EMERGENCY DEPT VISIT","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99285","description":"EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KE","allowed_amounts":[{"tin":{"type":"ein","value":"922826272"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":4767.26,"providers":[{"billed_charge":23148.00,"npi":[1073386421]}]}]}]},{"name":"NURSING FAC CARE SUBSEQ","billing_code_type":"CPT","billing_code_type_version":"2022","billing_code":"99308","description":"SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQ","allowed_amounts":[{"tin":{"type":"ein","value":"921487650"},"service_code":["31"],"billing_class":"professional","payments":[{"allowed_amount":473.40,"providers":[{"billed_charge":625.00,"npi":[1760811582]}]}]}]},{"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":"116000463"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1443.00,"providers":[{"billed_charge":1443.00,"npi":[1912009812]}]}]},{"tin":{"type":"ein","value":"133062687"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":2884.56,"providers":[{"billed_charge":2884.56,"npi":[1053351700]}]}]},{"tin":{"type":"ein","value":"202081121"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":2412.96,"providers":[{"billed_charge":2853.92,"npi":[1265542765]}]}]},{"tin":{"type":"ein","value":"141597784"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":150.00,"providers":[{"billed_charge":150.00,"npi":[1770562910]}]}]},{"tin":{"type":"ein","value":"132646815"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":16310.50,"providers":[{"billed_charge":22263.50,"npi":[1003878596]}]}]},{"tin":{"type":"ein","value":"132655001"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":3075.90,"providers":[{"billed_charge":3698.00,"npi":[1083715460]}]}]},{"tin":{"type":"ein","value":"112420013"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":3855.40,"providers":[{"billed_charge":4302.80,"npi":[1033343389]}]}]}]},{"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":"116000463"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":11710.62,"providers":[{"billed_charge":11710.62,"npi":[1912009812]}]}]},{"tin":{"type":"ein","value":"132655001"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":21250.00,"providers":[{"billed_charge":21906.00,"npi":[1083715460]}]}]},{"tin":{"type":"ein","value":"112420013"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":28318.00,"providers":[{"billed_charge":29400.00,"npi":[1033343389]}]}]}]},{"name":"AMB SERVICE BLS EMERGENCY TR","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"A0429","description":"AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS, EMERGENCY)","allowed_amounts":[{"tin":{"type":"ein","value":"202081121"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":9066.10,"providers":[{"billed_charge":9402.54,"npi":[1265542765]}]}]},{"tin":{"type":"ein","value":"132655001"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":79101.00,"providers":[{"billed_charge":85870.00,"npi":[1083715460]}]}]},{"tin":{"type":"ein","value":"112420013"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":25483.00,"providers":[{"billed_charge":26400.00,"npi":[1033343389]}]}]}]},{"name":"COLL V BLD VP/URN SMP CATH I","billing_code_type":"HCPCS","billing_code_type_version":"2022","billing_code":"G0471","description":"COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE OR URINE SAMPLE BY CATHETERIZATION FROM AN INDIVIDUAL IN","allowed_amounts":[{"tin":{"type":"ein","value":"843016042"},"service_code":["31"],"billing_class":"professional","payments":[{"allowed_amount":15.80,"providers":[{"billed_charge":200.00,"npi":[1598315574]}]}]}]}]}