{"reporting_entity_name":"Key Benefit Administrators, Inc.","reporting_entity_type":"Third-Party Administrator","last_updated_on":"2026-05-01","version":"2.0.0","out_of_network":[{"name":"SURGERY                OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"67028","description":"injection eye drug","allowed_amounts":[{"tin":{"type":"ein","value":"200121578","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":217.00,"providers":[{"billed_charge":217.00,"npi":[1003909789]}]}]},{"tin":{"type":"ein","value":"200121637","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":500.00,"providers":[{"billed_charge":500.00,"npi":[1053758136]}]}]}]},{"name":"VISION CARE DIAG TESTS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"92134","description":"cptr ophth dx img post segmt","allowed_amounts":[{"tin":{"type":"ein","value":"200121637","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":76.00,"providers":[{"billed_charge":76.00,"npi":[1053758136]}]}]}]},{"name":"VISION CARE DIAG TESTS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"92235","description":"fluorescein angrph mltiframe","allowed_amounts":[{"tin":{"type":"ein","value":"200121637","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":200.00,"providers":[{"billed_charge":200.00,"npi":[1053758136]}]}]}]},{"name":"DIAG SRVC/PROC         OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"92250","description":"fundus photography w/i&r","allowed_amounts":[{"tin":{"type":"ein","value":"200121637","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":127.00,"providers":[{"billed_charge":127.00,"npi":[1053758136]}]}]}]},{"name":"ROUTINE OFFICE/OP EXAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99213","description":"office o/p est low 20 min","allowed_amounts":[{"tin":{"type":"ein","value":"200121637","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":200.00,"providers":[{"billed_charge":200.00,"npi":[1053758136]}]}]},{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":205.75,"providers":[{"billed_charge":205.75,"npi":[1316298235,1396953485,1730682295]}]}]},{"tin":{"type":"ein","value":"470493594","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":175.00,"providers":[{"billed_charge":175.00,"npi":[1629575345]}]}]},{"tin":{"type":"ein","value":"470802902","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":180.00,"providers":[{"billed_charge":180.00,"npi":[1730720533]}]}]},{"tin":{"type":"ein","value":"470834673","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":115.00,"providers":[{"billed_charge":115.00,"npi":[1710944483]}]}]},{"tin":{"type":"ein","value":"824477423","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":146.00,"providers":[{"billed_charge":146.00,"npi":[1780607556]}]}]}]},{"name":"SURGERY                OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"20610","description":"drain/inj joint/bursa w/o us","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":115.87,"providers":[{"billed_charge":149.42,"npi":[1790840791]}]}]}]},{"name":"CONTRACEPTIVE SURGERY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"58300","description":"insert intrauterine device","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":242.71,"providers":[{"billed_charge":242.71,"npi":[1851398796]}]}]}]},{"name":"CONTRACEPTIVE SURGERY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"58301","description":"remove intrauterine device","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":254.59,"providers":[{"billed_charge":254.59,"npi":[1851398796]}]}]}]},{"name":"PHYSICIAN X-RAY/DIAG   OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"76801","description":"ob us < 14 wks single fetus","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":329.40,"providers":[{"billed_charge":329.40,"npi":[1003045014]}]}]}]},{"name":"PHYSICIAN X-RAY/DIAG   OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"76802","description":"ob us < 14 wks addl fetus","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":173.77,"providers":[{"billed_charge":173.77,"npi":[1003045014]}]}]}]},{"name":"INJ/IMMUN ADMINISTRATION","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90471","description":"immunization admin","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":44.66,"providers":[{"billed_charge":44.66,"npi":[1336553890]}]}]}]},{"name":"IMMUNIZATIONS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90715","description":"tdap vaccine 7 yrs/> im","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":91.42,"providers":[{"billed_charge":91.42,"npi":[1336553890]}]}]}]},{"name":"ROUTINE OFFICE/OP EXAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99212","description":"office o/p est sf 10 min","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":127.50,"providers":[{"billed_charge":127.50,"npi":[1851398796]}]}]}]},{"name":"ROUTINE OFFICE/OP EXAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99214","description":"office o/p est mod 30 min","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":290.81,"providers":[{"billed_charge":290.81,"npi":[1336553890,1497980056]}]}]},{"tin":{"type":"ein","value":"510147309","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":155.00,"providers":[{"billed_charge":155.00,"npi":[1427334739]}]}]},{"tin":{"type":"ein","value":"800348943","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":254.00,"providers":[{"billed_charge":254.00,"npi":[1174795017]}]}]}]},{"name":"ROUTINE OFFICE/OP EXAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99215","description":"office o/p est hi 40 min","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":408.90,"providers":[{"billed_charge":408.90,"npi":[1497980056]}]}]}]},{"name":"ROUTINE OFFICE/OP EXAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99385","description":"prev visit new age 18-39","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":293.32,"providers":[{"billed_charge":293.32,"npi":[1740501121,1851398796]}]}]}]},{"name":"ROUTINE OFFICE/OP EXAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99395","description":"prev visit est age 18-39","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":265.03,"providers":[{"billed_charge":265.03,"npi":[1336553890]}]}]},{"tin":{"type":"ein","value":"470493594","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":226.00,"providers":[{"billed_charge":226.00,"npi":[1851435994]}]}]}]},{"name":"PHYS OFFICE/OP VISITS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"G2211","description":"complex e/m visit add on","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":42.07,"providers":[{"billed_charge":42.07,"npi":[1336553890]}]}]},{"tin":{"type":"ein","value":"470785575","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":45.00,"providers":[{"billed_charge":45.00,"npi":[1720432008]}]}]}]},{"name":"THERAPEAUTIC INJ       OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"J1100","description":"dexamethasone sodium phos","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.48,"providers":[{"billed_charge":3.28,"npi":[1790840791]}]}]}]},{"name":"THERAPEAUTIC INJ","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"J2003","description":"Inj, lidocaine hydrochloride, 1mg","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.28,"providers":[{"billed_charge":0.50,"npi":[1790840791]}]},{"allowed_amount":1.10,"providers":[{"billed_charge":2.00,"npi":[1790840791]}]}]}]},{"name":"THERAPEAUTIC INJ       OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"J3301","description":"triamcinolone acet inj nos","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":3.80,"providers":[{"billed_charge":7.44,"npi":[1790840791]}]}]},{"tin":{"type":"ein","value":"824477423","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":20.00,"providers":[{"billed_charge":20.00,"npi":[1780607556]}]}]}]},{"name":"CONTRACEPTIVE DEVICES","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"J7298","description":"mirena, 52 mg","allowed_amounts":[{"tin":{"type":"ein","value":"363314159","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1388.15,"providers":[{"billed_charge":1388.15,"npi":[1851398796]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97010","description":"hot or cold packs therapy","allowed_amounts":[{"tin":{"type":"ein","value":"454024426","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":15.00,"providers":[{"billed_charge":15.00,"npi":[1093018517]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97110","description":"therapeutic exercises","allowed_amounts":[{"tin":{"type":"ein","value":"454024426","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"providers":[{"billed_charge":60.00,"npi":[1093018517]}]}]},{"tin":{"type":"ein","value":"470834673","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":70.00,"providers":[{"billed_charge":70.00,"npi":[1366972044]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97116","description":"gait training therapy","allowed_amounts":[{"tin":{"type":"ein","value":"454024426","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":50.00,"providers":[{"billed_charge":50.00,"npi":[1093018517]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97140","description":"manual therapy 1/> regions","allowed_amounts":[{"tin":{"type":"ein","value":"454024426","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":55.00,"providers":[{"billed_charge":55.00,"npi":[1093018517]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97164","description":"pt re-eval est plan care","allowed_amounts":[{"tin":{"type":"ein","value":"454024426","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":100.00,"providers":[{"billed_charge":100.00,"npi":[1093018517]}]}]}]},{"name":"DIAGNOSTIC XRAYS       OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"72100","description":"x-ray exam l-s spine 2/3 vws","allowed_amounts":[{"tin":{"type":"ein","value":"462747231","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":70.00,"providers":[{"billed_charge":70.00,"npi":[1316027204]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97012","description":"mechanical traction therapy","allowed_amounts":[{"tin":{"type":"ein","value":"462747231","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":35.00,"providers":[{"billed_charge":35.00,"npi":[1316027204]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97032","description":"appl modality 1+estim ea 15","allowed_amounts":[{"tin":{"type":"ein","value":"462747231","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":35.00,"providers":[{"billed_charge":35.00,"npi":[1316027204]}]}]}]},{"name":"CHIROPRACTIC","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"98941","description":"chiropract manj 3-4 regions","allowed_amounts":[{"tin":{"type":"ein","value":"462747231","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":65.00,"providers":[{"billed_charge":65.00,"npi":[1316027204]}]}]},{"tin":{"type":"ein","value":"470840547","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":45.00,"providers":[{"billed_charge":45.00,"npi":[1326272659]}]},{"allowed_amount":55.00,"providers":[{"billed_charge":55.00,"npi":[1740384841]}]}]}]},{"name":"ROUTINE OFFICE/OP EXAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99202","description":"office o/p new sf 15 min","allowed_amounts":[{"tin":{"type":"ein","value":"462747231","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":135.00,"providers":[{"billed_charge":135.00,"npi":[1316027204]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":15.00,"providers":[{"billed_charge":15.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"470493594","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":10.00,"providers":[{"billed_charge":10.00,"npi":[1851435994]}]}]},{"tin":{"type":"ein","value":"834081563","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":49.00,"providers":[{"billed_charge":49.00,"npi":[1568922862]}]}]}]},{"name":"DIAGNOSTIC XRAYS       OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"71045","description":"x-ray exam chest 1 view","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":29.30,"providers":[{"billed_charge":29.30,"npi":[1750624979]}]},{"allowed_amount":432.00,"providers":[{"billed_charge":432.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":29.30,"providers":[{"billed_charge":29.30,"npi":[1750624979]}]},{"allowed_amount":432.00,"providers":[{"billed_charge":432.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL XRAY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"71045","description":"x-ray exam chest 1 view","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":29.30,"providers":[{"billed_charge":29.30,"npi":[1750624979]}]},{"allowed_amount":432.00,"providers":[{"billed_charge":432.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":29.30,"providers":[{"billed_charge":29.30,"npi":[1750624979]}]},{"allowed_amount":432.00,"providers":[{"billed_charge":432.00,"npi":[1639101199]}]}]}]},{"name":"PHYSICIAN CT/MRI/PET SCAN","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"74177","description":"ct abd & pelv w/contrast","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":254.60,"providers":[{"billed_charge":254.60,"npi":[1487090528]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80048","description":"metabolic panel total ca","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":59.00,"providers":[{"billed_charge":59.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80053","description":"comprehen metabolic panel","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":71.00,"providers":[{"billed_charge":71.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"834081563","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":84.00,"providers":[{"billed_charge":84.00,"npi":[1568922862]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80061","description":"lipid panel","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":123.00,"providers":[{"billed_charge":123.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80076","description":"hepatic function panel","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":65.00,"providers":[{"billed_charge":65.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82306","description":"vitamin d 25 hydroxy","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":136.00,"providers":[{"billed_charge":136.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82607","description":"vitamin b-12","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":109.00,"providers":[{"billed_charge":109.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83036","description":"hemoglobin glycosylated a1c","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":48.00,"providers":[{"billed_charge":48.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83735","description":"assay of magnesium","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":43.00,"providers":[{"billed_charge":43.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84439","description":"assay of free thyroxine","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":59.00,"providers":[{"billed_charge":59.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84443","description":"ASSAY THYROID STIM HORMONE","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":83.00,"providers":[{"billed_charge":83.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85025","description":"complete cbc w/auto diff wbc","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":57.00,"providers":[{"billed_charge":57.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"834081563","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":75.00,"providers":[{"billed_charge":75.00,"npi":[1568922862]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87624","description":"hpv high-risk types","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":136.00,"providers":[{"billed_charge":136.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL LAB","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"88142","description":"cytopath c/v thin layer","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":90.00,"providers":[{"billed_charge":90.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL XRAY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"93005","description":"electrocardiogram tracing","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":437.00,"providers":[{"billed_charge":437.00,"npi":[1639101199]}]}]}]},{"name":"PHYSICIAN IP/OP SERVICES","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99284","description":"emergency dept visit mod mdm","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":269.64,"providers":[{"billed_charge":269.64,"npi":[1891732277]}]},{"allowed_amount":1935.00,"providers":[{"billed_charge":1935.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":269.64,"providers":[{"billed_charge":269.64,"npi":[1891732277]}]},{"allowed_amount":1935.00,"providers":[{"billed_charge":1935.00,"npi":[1639101199]}]}]}]},{"name":"EMERGENCY ROOM","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99284","description":"emergency dept visit mod mdm","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":269.64,"providers":[{"billed_charge":269.64,"npi":[1891732277]}]},{"allowed_amount":1935.00,"providers":[{"billed_charge":1935.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":269.64,"providers":[{"billed_charge":269.64,"npi":[1891732277]}]},{"allowed_amount":1935.00,"providers":[{"billed_charge":1935.00,"npi":[1639101199]}]}]}]},{"name":"HOSPITAL MISC CHARGE","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"J8540","description":"oral dexamethasone","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":3.14,"providers":[{"billed_charge":3.14,"npi":[1639101199]}]}]}]},{"name":"VENIPNCT/COLLECT/HANDL OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":15.00,"providers":[{"billed_charge":15.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"470493594","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":10.00,"providers":[{"billed_charge":10.00,"npi":[1851435994]}]}]},{"tin":{"type":"ein","value":"834081563","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":49.00,"providers":[{"billed_charge":49.00,"npi":[1568922862]}]}]}]},{"name":"ROUTINE OFFICE/OP EXAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99205","description":"office o/p new hi 60 min","allowed_amounts":[{"tin":{"type":"ein","value":"470785575","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":600.00,"providers":[{"billed_charge":600.00,"npi":[1720432008]}]}]}]},{"name":"DIAGNOSTIC XRAYS       OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"74018","description":"x-ray exam abdomen 1 view","allowed_amounts":[{"tin":{"type":"ein","value":"470802902","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":140.00,"providers":[{"billed_charge":140.00,"npi":[1730720533]}]}]}]},{"name":"CHRNC DIS MGMT LABS    OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81003","description":"urinalysis auto w/o scope","allowed_amounts":[{"tin":{"type":"ein","value":"470802902","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":27.00,"providers":[{"billed_charge":27.00,"npi":[1730720533]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97530","description":"therapeutic activities","allowed_amounts":[{"tin":{"type":"ein","value":"470834673","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":120.00,"providers":[{"billed_charge":120.00,"npi":[1366972044]}]}]}]},{"name":"INJ/IMMUN ADMINISTRATION","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96372","description":"ther/proph/diag inj sc/im","allowed_amounts":[{"tin":{"type":"ein","value":"824477423","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":38.00,"providers":[{"billed_charge":38.00,"npi":[1780607556]}]}]}]},{"name":"PHYSICIAN X-RAY/DIAG   OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"76642","description":"ultrasound breast limited","allowed_amounts":[{"tin":{"type":"ein","value":"830332945","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":480.59,"providers":[{"billed_charge":480.59,"npi":[1346534294]}]}]}]},{"name":"MAMMOGRAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"77061","description":"breast tomosynthesis uni","allowed_amounts":[{"tin":{"type":"ein","value":"830332945","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":247.20,"providers":[{"billed_charge":247.20,"npi":[1346534294]}]}]}]},{"name":"MAMMOGRAMS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"77065","description":"dx mammo incl cad uni","allowed_amounts":[{"tin":{"type":"ein","value":"830332945","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":378.74,"providers":[{"billed_charge":378.74,"npi":[1346534294]}]}]}]},{"name":"CHRNC DIS MGMT LABS    OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80053","description":"comprehen metabolic panel","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":71.00,"providers":[{"billed_charge":71.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"834081563","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":84.00,"providers":[{"billed_charge":84.00,"npi":[1568922862]}]}]}]},{"name":"CHRNC DIS MGMT LABS    OV","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85025","description":"complete cbc w/auto diff wbc","allowed_amounts":[{"tin":{"type":"ein","value":"470385129","business_name":null},"billing_class":"institutional","payments":[{"allowed_amount":57.00,"providers":[{"billed_charge":57.00,"npi":[1639101199]}]}]},{"tin":{"type":"ein","value":"834081563","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":75.00,"providers":[{"billed_charge":75.00,"npi":[1568922862]}]}]}]},{"name":"CHRONIC DIS MGMT LABS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85652","description":"rbc sed rate automated","allowed_amounts":[{"tin":{"type":"ein","value":"834081563","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":55.00,"providers":[{"billed_charge":55.00,"npi":[1568922862]}]}]}]},{"name":"CHRONIC DIS MGMT LABS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86140","description":"c-reactive protein","allowed_amounts":[{"tin":{"type":"ein","value":"834081563","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":77.00,"providers":[{"billed_charge":77.00,"npi":[1568922862]}]}]}]},{"name":"ANESTHESIA","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"00813","description":"anes upr lwr gi ndsc px","allowed_amounts":[{"tin":{"type":"ein","value":"841439630","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1750.00,"providers":[{"billed_charge":1750.00,"npi":[1740814235]}]}]}]}]}