{"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":"DIAGNOSTIC SRVC/PROC","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"93010","description":"electrocardiogram report","allowed_amounts":[{"tin":{"type":"ein","value":"340714585","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":7.60,"providers":[{"billed_charge":74.00,"npi":[1477648830]}]}]},{"tin":{"type":"ein","value":"630840996","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":7.37,"providers":[{"billed_charge":56.00,"npi":[1952527574]}]}]},{"tin":{"type":"ein","value":"630925859","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":7.25,"providers":[{"billed_charge":25.00,"npi":[1306373261]}]}]}]},{"name":"TELEPHONE/INTERNET CONSUL","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"98006","description":"synchronous audio-video visit est mod mdm 30 min","allowed_amounts":[{"tin":{"type":"ein","value":"340714585","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":692.00,"providers":[{"billed_charge":692.00,"npi":[1427141902]}]}]}]},{"name":"PHYSICIAN OFFICE 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":"340714585","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":142.00,"providers":[{"billed_charge":142.00,"npi":[1427141902]}]}]},{"tin":{"type":"ein","value":"363683493","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":14.87,"providers":[{"billed_charge":30.12,"npi":[1639176464]}]}]}]},{"name":"PHYSICIAN OFFICE VISITS","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":"363683493","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":25.52,"providers":[{"billed_charge":234.88,"npi":[1639176464]}]}]},{"tin":{"type":"ein","value":"382043826","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":102.71,"providers":[{"billed_charge":198.00,"npi":[1043857196]}]}]},{"tin":{"type":"ein","value":"382869822","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":120.84,"providers":[{"billed_charge":145.00,"npi":[1013000819]}]}]},{"tin":{"type":"ein","value":"631137578","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":114.89,"providers":[{"billed_charge":285.00,"npi":[1164443792]}]}]}]},{"name":"I/P-O/P PHYS VISITS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"G0537","description":"RISK ASCVD TST ONCE PR 12 MO","allowed_amounts":[{"tin":{"type":"ein","value":"382043826","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":14.79,"providers":[{"billed_charge":25.00,"npi":[1043857196]}]}]}]},{"name":"PHYSICIAN OFFICE VISITS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"G0538","description":"ASCVD RSK MNG CLIN STF PR MO","allowed_amounts":[{"tin":{"type":"ein","value":"382043826","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":12.28,"providers":[{"billed_charge":20.00,"npi":[1043857196]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97110","description":"therapeutic exercises","allowed_amounts":[{"tin":{"type":"ein","value":"462193669","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":22.29,"providers":[{"billed_charge":35.00,"npi":[1902503519]}]}]},{"tin":{"type":"ein","value":"814567432","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":20.91,"providers":[{"billed_charge":56.50,"npi":[1285482158]}]}]},{"tin":{"type":"ein","value":"861954316","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":44.58,"providers":[{"billed_charge":110.00,"npi":[1831459593]}]}]}]},{"name":"DAY TREATMENT","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90791","description":"psych diagnostic evaluation","allowed_amounts":[{"tin":{"type":"ein","value":"462877739","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":260.00,"providers":[{"billed_charge":260.00,"npi":[1043934805]}]}]}]},{"name":"DAY TREATMENT","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90837","description":"psytx w pt 60 minutes","allowed_amounts":[{"tin":{"type":"ein","value":"462877739","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":220.00,"providers":[{"billed_charge":220.00,"npi":[1043934805]}]}]}]},{"name":"I/P-O/P PHYS VISITS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99223","description":"1st hosp ip/obs high 75","allowed_amounts":[{"tin":{"type":"ein","value":"464167313","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":154.97,"providers":[{"billed_charge":225.00,"npi":[1770694515]}]}]}]},{"name":"I/P-O/P PHYS VISITS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99232","description":"sbsq hosp ip/obs moderate 35","allowed_amounts":[{"tin":{"type":"ein","value":"464167313","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":65.62,"providers":[{"billed_charge":90.00,"npi":[1083893309]}]}]}]},{"name":"I/P-O/P PHYS VISITS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99239","description":"hosp ip/obs dschrg mgmt >30","allowed_amounts":[{"tin":{"type":"ein","value":"464167313","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":102.06,"providers":[{"billed_charge":110.00,"npi":[1558375667]}]}]}]},{"name":"I/P-O/P PHYS VISITS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99285","description":"emergency dept visit hi mdm","allowed_amounts":[{"tin":{"type":"ein","value":"630840996","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":159.59,"providers":[{"billed_charge":682.00,"npi":[1952527574]}]}]}]},{"name":"SURGERY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"30903","description":"control of nosebleed","allowed_amounts":[{"tin":{"type":"ein","value":"630925859","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":204.44,"providers":[{"billed_charge":583.00,"npi":[1841225125]}]}]}]},{"name":"DIAGNOSTIC SRVC/PROC","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"93306","description":"tte w/doppler complete","allowed_amounts":[{"tin":{"type":"ein","value":"630925859","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":61.59,"providers":[{"billed_charge":205.00,"npi":[1306373261]}]}]}]},{"name":"PHYSICIAN OFFICE VISITS","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":"630925859","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":80.88,"providers":[{"billed_charge":202.00,"npi":[1841225125]}]}]},{"tin":{"type":"ein","value":"752415520","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":87.89,"providers":[{"billed_charge":100.00,"npi":[1235495391]}]}]},{"tin":{"type":"ein","value":"810796211","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":68.47,"providers":[{"billed_charge":170.25,"npi":[1760497697]}]}]}]},{"name":"I/P-O/P PHYS VISITS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99222","description":"1st hosp ip/obs moderate 55","allowed_amounts":[{"tin":{"type":"ein","value":"630925859","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":116.10,"providers":[{"billed_charge":380.00,"npi":[1619382355]}]}]}]},{"name":"VENIPUNCTURE/BLOOD DRAWS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"631137578","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":9.09,"providers":[{"billed_charge":18.00,"npi":[1164443792]}]}]}]},{"name":"CDM LABS","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":"631137578","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":7.77,"providers":[{"billed_charge":20.00,"npi":[1164443792]}]}]}]},{"name":"SURGERY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"67028","description":"injection eye drug","allowed_amounts":[{"tin":{"type":"ein","value":"752415520","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":107.70,"providers":[{"billed_charge":550.00,"npi":[1235495391]}]}]}]},{"name":"XRAY","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":"752415520","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":31.05,"providers":[{"billed_charge":80.00,"npi":[1235495391]}]}]}]},{"name":"THERAPEUTIC INJECTIONS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"Q5147","description":"injection, afibercept-ayyh (pavblu, biosimilar,1mg","allowed_amounts":[{"tin":{"type":"ein","value":"752415520","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":1710.36,"providers":[{"billed_charge":2350.00,"npi":[1235495391]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97016","description":"vasopneumatic device therapy","allowed_amounts":[{"tin":{"type":"ein","value":"814567432","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":8.36,"providers":[{"billed_charge":42.25,"npi":[1285482158]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97112","description":"neuromuscular reeducation","allowed_amounts":[{"tin":{"type":"ein","value":"814567432","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":23.68,"providers":[{"billed_charge":57.05,"npi":[1285482158]}]}]}]},{"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":"814567432","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":19.54,"providers":[{"billed_charge":50.00,"npi":[1285482158]}]}]},{"tin":{"type":"ein","value":"843548431","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":20.82,"providers":[{"billed_charge":91.00,"npi":[1689639981]}]}]}]},{"name":"PHYSICAL THERAPY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"97530","description":"therapeutic activities","allowed_amounts":[{"tin":{"type":"ein","value":"814567432","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":33.10,"providers":[{"billed_charge":59.50,"npi":[1285482158]}]}]},{"tin":{"type":"ein","value":"843548431","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":86.36,"providers":[{"billed_charge":351.00,"npi":[1689639981]}]}]}]},{"name":"SURGERY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"20611","description":"drain/inj joint/bursa w/us","allowed_amounts":[{"tin":{"type":"ein","value":"843548431","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":99.37,"providers":[{"billed_charge":322.00,"npi":[1689639981]}]}]}]},{"name":"THERAPEUTIC INJECTIONS","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"J7324","description":"orthovisc inj per dose","allowed_amounts":[{"tin":{"type":"ein","value":"843548431","business_name":null},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":92.14,"providers":[{"billed_charge":277.00,"npi":[1689639981]}]}]}]}]}