{"reporting_entity_name":"Community Health Choice, Inc","reporting_entity_type":"Group Health Plan","plan_name":"Community Select Limited Network Gold Marketplace","plan_id_type":"HIOS","plan_id":"PEPGM0000000043","plan_market_type":"Individual","last_updated_on":"2026-07-14","out_of_network":[{"name":"GROUND MILEAGE PER STATUTE MILE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425","description":"GROUND MILEAGE PER STATUTE MILE","allowed_amounts":[{"tin":{"type":"ein","value":"746001164"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":154.1,"providers":[{"billed_charge":124.1,"npi":[1447375282]}]},{"allowed_amount":32.58,"providers":[{"billed_charge":32.58,"npi":[1447375282]}]},{"allowed_amount":114.03,"providers":[{"billed_charge":114.03,"npi":[1447375282]}]},{"allowed_amount":81.45,"providers":[{"billed_charge":81.45,"npi":[1447375282]}]},{"allowed_amount":33.04,"providers":[{"billed_charge":33.04,"npi":[1447375282]}]},{"allowed_amount":99.12,"providers":[{"billed_charge":99.12,"npi":[1447375282]}]},{"allowed_amount":82.6,"providers":[{"billed_charge":82.6,"npi":[1447375282]}]},{"allowed_amount":66.08,"providers":[{"billed_charge":66.08,"npi":[1447375282]}]},{"allowed_amount":181.72,"providers":[{"billed_charge":181.72,"npi":[1447375282]}]},{"allowed_amount":16.52,"providers":[{"billed_charge":16.52,"npi":[1447375282]}]},{"allowed_amount":49.56,"providers":[{"billed_charge":49.56,"npi":[1447375282]}]},{"allowed_amount":115.64,"providers":[{"billed_charge":115.64,"npi":[1447375282]}]},{"allowed_amount":198.24,"providers":[{"billed_charge":198.24,"npi":[1447375282]}]},{"allowed_amount":280.84,"providers":[{"billed_charge":280.84,"npi":[1447375282]}]},{"allowed_amount":148.68,"providers":[{"billed_charge":148.68,"npi":[1447375282]}]}]},{"tin":{"type":"ein","value":"208424689"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":2652,"providers":[{"billed_charge":2652,"npi":[1952588329]}]},{"allowed_amount":2771,"providers":[{"billed_charge":2771,"npi":[1952588329]}]},{"allowed_amount":289,"providers":[{"billed_charge":259,"npi":[1952588329]}]},{"allowed_amount":1581,"providers":[{"billed_charge":1551,"npi":[1952588329]}]},{"allowed_amount":1258,"providers":[{"billed_charge":1258,"npi":[1952588329]}]},{"allowed_amount":1045.5,"providers":[{"billed_charge":1045.5,"npi":[1952588329]}]},{"allowed_amount":1028.5,"providers":[{"billed_charge":1028.5,"npi":[1952588329]}]},{"allowed_amount":2099.5,"providers":[{"billed_charge":2099.5,"npi":[1952588329]}]},{"allowed_amount":2592.5,"providers":[{"billed_charge":2592.5,"npi":[1952588329]}]},{"allowed_amount":994.5,"providers":[{"billed_charge":994.5,"npi":[1952588329]}]},{"allowed_amount":748,"providers":[{"billed_charge":748,"npi":[1952588329]}]},{"allowed_amount":705.5,"providers":[{"billed_charge":705.5,"npi":[1952588329]}]},{"allowed_amount":1878.5,"providers":[{"billed_charge":1878.5,"npi":[1952588329]}]},{"allowed_amount":841.5,"providers":[{"billed_charge":841.5,"npi":[1952588329]}]},{"allowed_amount":1623.5,"providers":[{"billed_charge":1623.5,"npi":[1952588329]}]},{"allowed_amount":858.5,"providers":[{"billed_charge":858.5,"npi":[1952588329]}]},{"allowed_amount":1445,"providers":[{"billed_charge":1445,"npi":[1952588329]}]},{"allowed_amount":1674.5,"providers":[{"billed_charge":1674.5,"npi":[1952588329]}]},{"allowed_amount":2405.5,"providers":[{"billed_charge":2405.5,"npi":[1952588329]}]},{"allowed_amount":76.5,"providers":[{"billed_charge":76.5,"npi":[1952588329]}]},{"allowed_amount":467.5,"providers":[{"billed_charge":467.5,"npi":[1952588329]}]},{"allowed_amount":833,"providers":[{"billed_charge":833,"npi":[1952588329]}]},{"allowed_amount":2159,"providers":[{"billed_charge":2159,"npi":[1952588329]}]},{"allowed_amount":1589.5,"providers":[{"billed_charge":1589.5,"npi":[1952588329]}]},{"allowed_amount":1598,"providers":[{"billed_charge":1598,"npi":[1952588329]}]},{"allowed_amount":1844.5,"providers":[{"billed_charge":1844.5,"npi":[1952588329]}]},{"allowed_amount":1997.5,"providers":[{"billed_charge":1997.5,"npi":[1952588329]}]},{"allowed_amount":629,"providers":[{"billed_charge":629,"npi":[1952588329]}]},{"allowed_amount":2303.5,"providers":[{"billed_charge":2303.5,"npi":[1952588329]}]}]},{"tin":{"type":"ein","value":"201919780"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":398.2,"providers":[{"billed_charge":398.2,"npi":[1952995888]}]},{"allowed_amount":278.44,"providers":[{"billed_charge":278.44,"npi":[1952995888]}]},{"allowed_amount":332.33,"providers":[{"billed_charge":332.33,"npi":[1952995888]}]},{"allowed_amount":380.24,"providers":[{"billed_charge":380.24,"npi":[1952995888]}]},{"allowed_amount":227.54,"providers":[{"billed_charge":227.54,"npi":[1952995888]}]},{"allowed_amount":337.44,"providers":[{"billed_charge":337.44,"npi":[1952995888]}]},{"allowed_amount":79.04,"providers":[{"billed_charge":79.04,"npi":[1952995888]}]},{"allowed_amount":249.28,"providers":[{"billed_charge":249.28,"npi":[1952995888]}]},{"allowed_amount":419.52,"providers":[{"billed_charge":419.52,"npi":[1952995888]}]},{"allowed_amount":42.56,"providers":[{"billed_charge":42.56,"npi":[1952995888]}]},{"allowed_amount":57.76,"providers":[{"billed_charge":57.76,"npi":[1952995888]}]},{"allowed_amount":185.44,"providers":[{"billed_charge":185.44,"npi":[1952995888]}]},{"allowed_amount":197.6,"providers":[{"billed_charge":197.6,"npi":[1952995888]}]},{"allowed_amount":452.96,"providers":[{"billed_charge":452.96,"npi":[1952995888]}]},{"allowed_amount":300.96,"providers":[{"billed_charge":300.96,"npi":[1952995888]}]},{"allowed_amount":264.48,"providers":[{"billed_charge":264.48,"npi":[1952995888]}]},{"allowed_amount":334.4,"providers":[{"billed_charge":334.4,"npi":[1952995888]}]},{"allowed_amount":194.56,"providers":[{"billed_charge":194.56,"npi":[1952995888]}]},{"allowed_amount":380,"providers":[{"billed_charge":380,"npi":[1952995888]}]},{"allowed_amount":270.56,"providers":[{"billed_charge":270.56,"npi":[1952995888]}]},{"allowed_amount":255.36,"providers":[{"billed_charge":255.36,"npi":[1952995888]}]},{"allowed_amount":45.6,"providers":[{"billed_charge":45.6,"npi":[1952995888]}]},{"allowed_amount":182.4,"providers":[{"billed_charge":182.4,"npi":[1952995888]}]},{"allowed_amount":291.84,"providers":[{"billed_charge":291.84,"npi":[1952995888]}]},{"allowed_amount":118.56,"providers":[{"billed_charge":118.56,"npi":[1952995888]}]},{"allowed_amount":358.72,"providers":[{"billed_charge":358.72,"npi":[1952995888]}]},{"allowed_amount":170.24,"providers":[{"billed_charge":170.24,"npi":[1952995888]}]},{"allowed_amount":72.96,"providers":[{"billed_charge":72.96,"npi":[1952995888]}]}]},{"tin":{"type":"ein","value":"760133493"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":119.42,"providers":[{"billed_charge":119.42,"npi":[1760033526]}]},{"allowed_amount":136.48,"providers":[{"billed_charge":136.48,"npi":[1760033526]}]},{"allowed_amount":102.36,"providers":[{"billed_charge":102.36,"npi":[1760033526]},{"billed_charge":0,"npi":[1760033526]}]},{"allowed_amount":34.12,"providers":[{"billed_charge":34.12,"npi":[1760033526]}]},{"allowed_amount":51.18,"providers":[{"billed_charge":51.18,"npi":[1760033526]},{"billed_charge":0,"npi":[1760033526]}]},{"allowed_amount":187.66,"providers":[{"billed_charge":187.66,"npi":[1760033526]}]},{"allowed_amount":68.24,"providers":[{"billed_charge":68.24,"npi":[1760033526]},{"billed_charge":0,"npi":[1760033526]}]},{"allowed_amount":170.6,"providers":[{"billed_charge":170.6,"npi":[1760033526]}]},{"allowed_amount":153.54,"providers":[{"billed_charge":0,"npi":[1760033526]},{"billed_charge":153.54,"npi":[1760033526]}]},{"allowed_amount":85.3,"providers":[{"billed_charge":85.3,"npi":[1760033526]}]}]}]},{"name":"EMERGENCY DEPT VISIT LOW MDM","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99283","description":"EMERGENCY DEPT VISIT LOW MDM","allowed_amounts":[{"tin":{"type":"ein","value":"621801363"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":349.53,"providers":[{"billed_charge":0,"npi":[1275580938]}]},{"allowed_amount":360.54,"providers":[{"billed_charge":360.54,"npi":[1275580938]},{"billed_charge":0,"npi":[1275580938]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1275580938]},{"billed_charge":354.73,"npi":[1275580938]},{"billed_charge":248.31,"npi":[1275580938]},{"billed_charge":122.3,"npi":[1275580938]}]}]},{"tin":{"type":"ein","value":"621619857"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":349.53,"providers":[{"billed_charge":0,"npi":[1811942238]}]},{"allowed_amount":360.54,"providers":[{"billed_charge":360.54,"npi":[1811942238]},{"billed_charge":0,"npi":[1811942238]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1811942238]},{"billed_charge":354.73,"npi":[1811942238]},{"billed_charge":248.31,"npi":[1811942238]},{"billed_charge":152.28,"npi":[1811942238]},{"billed_charge":108.32,"npi":[1811942238]},{"billed_charge":94.15,"npi":[1811942238]}]}]},{"tin":{"type":"ein","value":"862533154"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1548847601]}]},{"allowed_amount":1048.02,"providers":[{"billed_charge":733.61,"npi":[1548847601]},{"billed_charge":0,"npi":[1548847601]},{"billed_charge":119.51,"npi":[1548847601]}]},{"allowed_amount":1152.82,"providers":[{"billed_charge":1152.82,"npi":[1548847601]}]}]},{"tin":{"type":"ein","value":"862559925"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":68.83,"providers":[{"billed_charge":68.83,"npi":[1649923806]}]},{"allowed_amount":221.13,"providers":[{"billed_charge":221.13,"npi":[1831503168]}]},{"allowed_amount":217.62,"providers":[{"billed_charge":217.62,"npi":[1306138631]}]},{"allowed_amount":218.63,"providers":[{"billed_charge":218.63,"npi":[1144630971,1477904704,1306138631,1649619719,1619256062,1336470426]}]},{"allowed_amount":82.16,"providers":[{"billed_charge":82.16,"npi":[1831503168]}]},{"allowed_amount":547.66,"providers":[{"billed_charge":547.66,"npi":[1376886317]}]},{"allowed_amount":74.69,"providers":[{"billed_charge":0,"npi":[1306138631]}]},{"allowed_amount":75.97,"providers":[{"billed_charge":0,"npi":[1649619719,1144343096,1619256062,1639220213,1306097944]},{"billed_charge":75.97,"npi":[1760772792,1306138631,1295056752,1730506007]},{"billed_charge":19.28,"npi":[1336470426]}]},{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1144343096]}]},{"allowed_amount":71.57,"providers":[{"billed_charge":71.57,"npi":[1477904704]},{"billed_charge":0,"npi":[1477904704]}]}]},{"tin":{"type":"ein","value":"852464463"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":217,"providers":[{"billed_charge":217,"npi":[1710919618]}]},{"allowed_amount":217.62,"providers":[{"billed_charge":217.62,"npi":[1992764419,1881155679,1669727053,1396840740]}]},{"allowed_amount":74.69,"providers":[{"billed_charge":0,"npi":[1962611103,1922208776,1992764419,1922595727,1700171014,1578022778]},{"billed_charge":74.69,"npi":[1992764419,1942565825,1144473570,1912355983]}]},{"allowed_amount":238.39,"providers":[{"billed_charge":238.39,"npi":[1962611103]}]},{"allowed_amount":456.39,"providers":[{"billed_charge":456.39,"npi":[1629418025]}]},{"allowed_amount":218.63,"providers":[{"billed_charge":218.63,"npi":[1710919618,1992764419,1922595727,1942565825,1962611103,1699102848,1144473570,1912355983,1922208776,1649568692,1710181664,1508094988,1578022778,1700171014,1750694196,1144487109,1124281456,1659755122,1073905097,1073545588,1396840740,1932395514,1235459769]}]},{"allowed_amount":253.2,"providers":[{"billed_charge":253.2,"npi":[1922208776,1922595727,1700171014,1710181664,1992764419,1073545588,1144473570]}]},{"allowed_amount":240.52,"providers":[{"billed_charge":240.52,"npi":[1982877387,1700171014,1811637846]}]},{"allowed_amount":381.06,"providers":[{"billed_charge":381.06,"npi":[1992764419]}]},{"allowed_amount":418.98,"providers":[{"billed_charge":418.98,"npi":[1629418025]}]},{"allowed_amount":70.65,"providers":[{"billed_charge":0,"npi":[1962611103,1699102848,1922595727,1710181664]},{"billed_charge":70.65,"npi":[1508094988]}]},{"allowed_amount":71.77,"providers":[{"billed_charge":0,"npi":[1649568692,1710181664,1144487109,1659755122,1073905097,1396840740,1942565825,1881155679,1124068416,1144473570,1699102848,1508094988,1982877387]},{"billed_charge":71.77,"npi":[1124068416,1710181664,1699102848]}]},{"allowed_amount":76.35,"providers":[{"billed_charge":0,"npi":[1922595727,1992764419,1922208776,1710919618,1932395514]},{"billed_charge":76.35,"npi":[1992764419]}]},{"allowed_amount":75.97,"providers":[{"billed_charge":0,"npi":[1578022778,1700171014,1750694196,1124281456,1144473570,1235459769,1073545588,1811637846,1073905097,1710181664,1851321582,1710919618,1962611103,1942565825,1659755122]},{"billed_charge":75.97,"npi":[1578022778,1073545588,1144473570,1073905097,1235459769,1124068416,1124281456,1710181664,1700095056]}]},{"allowed_amount":1308.85,"providers":[{"billed_charge":1308.85,"npi":[1578022778]}]},{"allowed_amount":72.12,"providers":[{"billed_charge":0,"npi":[1922208776,1912355983,1710919618]}]},{"allowed_amount":321.77,"providers":[{"billed_charge":321.77,"npi":[1235459769]}]},{"allowed_amount":217.63,"providers":[{"billed_charge":217.63,"npi":[1073545588]}]},{"allowed_amount":70.94,"providers":[{"billed_charge":0,"npi":[1013968064]}]}]},{"tin":{"type":"ein","value":"852713042"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":856.68,"providers":[{"billed_charge":856.68,"npi":[1376141556]}]},{"allowed_amount":822.01,"providers":[{"billed_charge":822.01,"npi":[1376141556]}]},{"allowed_amount":839.17,"providers":[{"billed_charge":839.17,"npi":[1376141556]}]},{"allowed_amount":1049.64,"providers":[{"billed_charge":1049.64,"npi":[1376141556]}]},{"allowed_amount":1321.38,"providers":[{"billed_charge":1321.38,"npi":[1376141556]}]},{"allowed_amount":845.46,"providers":[{"billed_charge":845.46,"npi":[1376141556]}]},{"allowed_amount":747.28,"providers":[{"billed_charge":0,"npi":[1376141556]},{"billed_charge":326.38,"npi":[1376141556]},{"billed_charge":747.28,"npi":[1376141556]},{"billed_charge":523.1,"npi":[1376141556]},{"billed_charge":397.25,"npi":[1376141556]},{"billed_charge":560.46,"npi":[1376141556]}]},{"allowed_amount":2754.2,"providers":[{"billed_charge":2754.2,"npi":[1376141556]}]},{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1376141556]}]},{"allowed_amount":1724.73,"providers":[{"billed_charge":1724.73,"npi":[1376141556]}]},{"allowed_amount":1828.3,"providers":[{"billed_charge":1828.3,"npi":[1376141556]}]},{"allowed_amount":1872.38,"providers":[{"billed_charge":1872.38,"npi":[1376141556]}]},{"allowed_amount":1037.7,"providers":[{"billed_charge":1037.7,"npi":[1376141556]}]},{"allowed_amount":1876.63,"providers":[{"billed_charge":1876.63,"npi":[1376141556]}]},{"allowed_amount":1928.7,"providers":[{"billed_charge":1928.7,"npi":[1376141556]}]},{"allowed_amount":1152.99,"providers":[{"billed_charge":1152.99,"npi":[1376141556]}]},{"allowed_amount":1066.98,"providers":[{"billed_charge":1066.98,"npi":[1376141556]}]},{"allowed_amount":1915.39,"providers":[{"billed_charge":1915.39,"npi":[1376141556]}]},{"allowed_amount":825.97,"providers":[{"billed_charge":825.97,"npi":[1376141556]}]},{"allowed_amount":1025.97,"providers":[{"billed_charge":1025.97,"npi":[1376141556]}]},{"allowed_amount":1916.97,"providers":[{"billed_charge":1916.97,"npi":[1376141556]}]},{"allowed_amount":1954.4,"providers":[{"billed_charge":1954.4,"npi":[1376141556]}]}]},{"tin":{"type":"ein","value":"993991604"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":217.62,"providers":[{"billed_charge":217.62,"npi":[1053601203,1508942947]}]},{"allowed_amount":218.63,"providers":[{"billed_charge":218.63,"npi":[1902223217,1538540208,1558655126,1851321582,1316992779,1497827851]}]},{"allowed_amount":1050.48,"providers":[{"billed_charge":1050.48,"npi":[1538102660]}]},{"allowed_amount":74.69,"providers":[{"billed_charge":0,"npi":[1538540208,1558655126,1851321582]}]},{"allowed_amount":272.63,"providers":[{"billed_charge":272.63,"npi":[1538540208]}]},{"allowed_amount":75.97,"providers":[{"billed_charge":0,"npi":[1538540208,1316992779,1407089154,1053601203,1396784286,1083676886,1700378148,1508094988]},{"billed_charge":75.97,"npi":[1497827851,1316992779,1538540208,1508094988,1083676886]}]},{"allowed_amount":1195.62,"providers":[{"billed_charge":1195.62,"npi":[1538540208]}]},{"allowed_amount":547.66,"providers":[{"billed_charge":547.66,"npi":[1407089154]}]},{"allowed_amount":270,"providers":[{"billed_charge":270,"npi":[1316992779]}]},{"allowed_amount":270.67,"providers":[{"billed_charge":270.67,"npi":[1316992779]}]}]},{"tin":{"type":"ein","value":"994033554"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":684.39,"providers":[{"billed_charge":684.39,"npi":[1912745274]}]},{"allowed_amount":1869.67,"providers":[{"billed_charge":1869.67,"npi":[1912745274]}]},{"allowed_amount":1238.5,"providers":[{"billed_charge":1238.5,"npi":[1912745274]}]},{"allowed_amount":1014.74,"providers":[{"billed_charge":1014.74,"npi":[1912745274]}]},{"allowed_amount":916.49,"providers":[{"billed_charge":0,"npi":[1912745274]},{"billed_charge":916.49,"npi":[1912745274]}]},{"allowed_amount":1008.14,"providers":[{"billed_charge":1008.14,"npi":[1912745274]}]},{"allowed_amount":1174.76,"providers":[{"billed_charge":1174.76,"npi":[1912745274]}]},{"allowed_amount":2658.65,"providers":[{"billed_charge":2658.65,"npi":[1912745274]}]},{"allowed_amount":1225.3,"providers":[{"billed_charge":1225.3,"npi":[1912745274]}]},{"allowed_amount":1218.7,"providers":[{"billed_charge":1218.7,"npi":[1912745274]}]},{"allowed_amount":212.11,"providers":[{"billed_charge":212.11,"npi":[1912745274]}]},{"allowed_amount":1212.1,"providers":[{"billed_charge":1212.1,"npi":[1912745274]}]},{"allowed_amount":1839.74,"providers":[{"billed_charge":1839.74,"npi":[1912745274]}]}]},{"tin":{"type":"ein","value":"465619077"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":240.52,"providers":[{"billed_charge":240.52,"npi":[1831285014,1588998397,1316680127,1396784286,1245279603,1316352933,1356421697,1356322416,1154333771,1710925359]}]},{"allowed_amount":238.89,"providers":[{"billed_charge":238.89,"npi":[1053759407,1417389206]}]},{"allowed_amount":74.69,"providers":[{"billed_charge":0,"npi":[1649211939,1356322416]},{"billed_charge":74.69,"npi":[1356421697]}]},{"allowed_amount":311.35,"providers":[{"billed_charge":311.35,"npi":[1649211939]}]},{"allowed_amount":69.75,"providers":[{"billed_charge":0,"npi":[1316352933]}]},{"allowed_amount":75.97,"providers":[{"billed_charge":75.97,"npi":[1396784286,1710925359,1518935550,1720738602,1649211939]},{"billed_charge":0,"npi":[1588998397,1396784286,1720738602,1649211939,1629418025]}]},{"allowed_amount":71.77,"providers":[{"billed_charge":0,"npi":[1154333771]}]},{"allowed_amount":76.35,"providers":[{"billed_charge":0,"npi":[1073966222]}]},{"allowed_amount":76.22,"providers":[{"billed_charge":0,"npi":[1053759407]}]}]},{"tin":{"type":"ein","value":"823463299"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":2288.26,"providers":[{"billed_charge":2288.26,"npi":[1649770488]}]},{"allowed_amount":1165.68,"providers":[{"billed_charge":0,"npi":[1649770488]},{"billed_charge":631.13,"npi":[1649770488]},{"billed_charge":448.31,"npi":[1649770488]},{"billed_charge":874.26,"npi":[1649770488]},{"billed_charge":815.98,"npi":[1649770488]}]},{"allowed_amount":1282.25,"providers":[{"billed_charge":1282.25,"npi":[1649770488]}]},{"allowed_amount":1335.02,"providers":[{"billed_charge":1335.02,"npi":[1649770488]}]},{"allowed_amount":1764.47,"providers":[{"billed_charge":1764.47,"npi":[1649770488]}]},{"allowed_amount":2268.59,"providers":[{"billed_charge":2268.59,"npi":[1649770488]}]},{"allowed_amount":1510.82,"providers":[{"billed_charge":1510.82,"npi":[1649770488]}]},{"allowed_amount":2869.45,"providers":[{"billed_charge":2869.45,"npi":[1649770488]}]},{"allowed_amount":2937.41,"providers":[{"billed_charge":2937.41,"npi":[1649770488]}]}]},{"tin":{"type":"ein","value":"873769568"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":77.72,"providers":[{"billed_charge":77.72,"npi":[1629143029]}]},{"allowed_amount":70.65,"providers":[{"billed_charge":0,"npi":[1801095880,1629143029]}]},{"allowed_amount":218.63,"providers":[{"billed_charge":218.63,"npi":[1801095880,1629143029]}]},{"allowed_amount":71.77,"providers":[{"billed_charge":0,"npi":[1801095880,1629143029,1821059841]},{"billed_charge":71.77,"npi":[1629143029,1184942112]}]},{"allowed_amount":309.81,"providers":[{"billed_charge":309.81,"npi":[1801095880]}]}]},{"tin":{"type":"ein","value":"882501936"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":1713.01,"providers":[{"billed_charge":1713.01,"npi":[1750013769]}]},{"allowed_amount":1916.97,"providers":[{"billed_charge":1916.97,"npi":[1750013769]}]},{"allowed_amount":747.28,"providers":[{"billed_charge":0,"npi":[1750013769]},{"billed_charge":747.28,"npi":[1750013769]},{"billed_charge":560.46,"npi":[1750013769]},{"billed_charge":119.61,"npi":[1750013769]}]},{"allowed_amount":875.92,"providers":[{"billed_charge":875.92,"npi":[1750013769]}]},{"allowed_amount":1025.97,"providers":[{"billed_charge":1025.97,"npi":[1750013769]}]},{"allowed_amount":1808.14,"providers":[{"billed_charge":1808.14,"npi":[1750013769]}]},{"allowed_amount":822.01,"providers":[{"billed_charge":822.01,"npi":[1750013769]}]},{"allowed_amount":2268.26,"providers":[{"billed_charge":2268.26,"npi":[1750013769]}]}]},{"tin":{"type":"ein","value":"760545192"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":360.54,"providers":[{"billed_charge":360.54,"npi":[1871619254,1083937593]},{"billed_charge":0,"npi":[1083937593,1629828405,1871619254,1184179194]}]},{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1083937593]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1871619254,1083937593,1497871628,1184179194]},{"billed_charge":354.73,"npi":[1083937593,1871619254,1497871628]},{"billed_charge":248.31,"npi":[1083937593,1871619254]},{"billed_charge":143.4,"npi":[1083937593]},{"billed_charge":232.86,"npi":[1083937593]},{"billed_charge":46.17,"npi":[1083937593]},{"billed_charge":239.67,"npi":[1083937593]},{"billed_charge":266.05,"npi":[1497871628]},{"billed_charge":200.68,"npi":[1083937593]},{"billed_charge":236.75,"npi":[1083937593]}]},{"allowed_amount":356.49,"providers":[{"billed_charge":249.54,"npi":[1629828405]},{"billed_charge":356.49,"npi":[1629828405]},{"billed_charge":0,"npi":[1629828405]}]},{"allowed_amount":3415.65,"providers":[{"billed_charge":1251.85,"npi":[1629828405]}]}]},{"tin":{"type":"ein","value":"821635538"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":360.54,"providers":[{"billed_charge":0,"npi":[1073043592]},{"billed_charge":360.54,"npi":[1073043592]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1073043592]},{"billed_charge":354.73,"npi":[1073043592]},{"billed_charge":248.31,"npi":[1073043592]}]}]},{"tin":{"type":"ein","value":"821349955"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":360.54,"providers":[{"billed_charge":360.54,"npi":[1750819025]},{"billed_charge":0,"npi":[1750819025]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1750819025]},{"billed_charge":248.31,"npi":[1750819025]},{"billed_charge":354.73,"npi":[1750819025]},{"billed_charge":46.63,"npi":[1750819025]}]}]},{"tin":{"type":"ein","value":"742501542"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":74.69,"providers":[{"billed_charge":0,"npi":[1255907598,1265051361]},{"billed_charge":74.69,"npi":[1225693963]}]},{"allowed_amount":70.65,"providers":[{"billed_charge":0,"npi":[1124412267]}]},{"allowed_amount":75.97,"providers":[{"billed_charge":0,"npi":[1336713932,1952862740,1548550221,1245499235,1154402188,1346620598]},{"billed_charge":75.97,"npi":[1366962193,1912999483,1285167320]}]},{"allowed_amount":64.58,"providers":[{"billed_charge":0,"npi":[1811147820,1265082358,1558873349,1518499672,1376946749,1982044210]},{"billed_charge":64.58,"npi":[1952878811,1437637386,1982044210]}]},{"allowed_amount":76.35,"providers":[{"billed_charge":76.35,"npi":[1225693963,1811526270]}]}]},{"tin":{"type":"ein","value":"260834681"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":74.69,"providers":[{"billed_charge":0,"npi":[1003375130,1740286517,1285618280]}]},{"allowed_amount":75.97,"providers":[{"billed_charge":0,"npi":[1326067612,1558757005,1497997142,1871971440,1417390063,1194805531,1669409892,1316488760,1407075567,1104245257,1043288988,1982044459,1255725164,1275943946,1851405971,1275020505]}]},{"allowed_amount":64.58,"providers":[{"billed_charge":0,"npi":[1336588730,1700353323,1306118161,1861835886,1457999583,1417666751,1871295592,1306590807,1962265637,1568747111]},{"billed_charge":64.58,"npi":[1306388392]}]}]},{"tin":{"type":"ein","value":"463902289"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":74.69,"providers":[{"billed_charge":0,"npi":[1518100064,1326465246,1649408691,1063447415,1336105774,1972705333,1952798126,1740429208,1639494412]}]},{"allowed_amount":75.97,"providers":[{"billed_charge":0,"npi":[1063417715,1275818536,1619295888,1649345273,1477561199,1518988393,1326465246,1750658704,1790075943,1710333521,1063447415,1891716601,1316964877,1225086606,1427010768,1770512253,1285924142,1427385624,1992149538,1336105774,1841441334,1326149931,1821330044,1215137559,1366488298,1548670326,1083850176,1962723288,1639494412,1629381538,1972705333,1265499909,1144588724,1689608432,1326660309,1952798126,1437441664]},{"billed_charge":75.97,"npi":[1548670326,1689608432,1952862740,1982998308,1063447415,1811221211,1952798126,1740429208,1477561199,1790075943,1427010768]},{"billed_charge":58.26,"npi":[1649666249]}]},{"allowed_amount":71.77,"providers":[{"billed_charge":0,"npi":[1134113699,1811162803]},{"billed_charge":71.77,"npi":[1790729911,1811162803]}]}]},{"tin":{"type":"ein","value":"741100555"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":360.54,"providers":[{"billed_charge":0,"npi":[1477643690]},{"billed_charge":360.54,"npi":[1477643690]}]},{"allowed_amount":668.8,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":645.33,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1477643690]},{"billed_charge":354.73,"npi":[1477643690]},{"billed_charge":248.31,"npi":[1477643690]}]},{"allowed_amount":671.19,"providers":[{"billed_charge":469.83,"npi":[1477643690]},{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":521.6,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":519.57,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":745.34,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":521.2,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":514.71,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":940.5,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":514.03,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":1588.31,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":543.06,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":706.02,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":629.6,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":762.91,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":704.57,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":553.1,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":558.35,"providers":[{"billed_charge":0,"npi":[1477643690]}]},{"allowed_amount":543.54,"providers":[{"billed_charge":0,"npi":[1477643690]}]}]},{"tin":{"type":"ein","value":"621801359"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":360.54,"providers":[{"billed_charge":0,"npi":[1174576698]},{"billed_charge":252.38,"npi":[1174576698]},{"billed_charge":360.54,"npi":[1174576698]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1174576698]},{"billed_charge":354.73,"npi":[1174576698]},{"billed_charge":248.31,"npi":[1174576698]}]}]},{"tin":{"type":"ein","value":"741180155"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":360.54,"providers":[{"billed_charge":0,"npi":[1548387418]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1548387418]},{"billed_charge":354.73,"npi":[1548387418]},{"billed_charge":248.31,"npi":[1548387418]}]}]},{"tin":{"type":"ein","value":"844964431"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":74.69,"providers":[{"billed_charge":0,"npi":[1295049856]}]},{"allowed_amount":204.52,"providers":[{"billed_charge":204.52,"npi":[1295049856]}]},{"allowed_amount":75.97,"providers":[{"billed_charge":0,"npi":[1184704413,1295049856,1194162065,1740268366,1639438385]},{"billed_charge":75.97,"npi":[1447631353,1578588984]}]},{"allowed_amount":240.52,"providers":[{"billed_charge":240.52,"npi":[1184704413,1639438385,1295049856,1710908504,1447631353]}]},{"allowed_amount":76.35,"providers":[{"billed_charge":0,"npi":[1639438385]}]},{"allowed_amount":71.77,"providers":[{"billed_charge":0,"npi":[1710908504]},{"billed_charge":71.77,"npi":[1710908504]},{"billed_charge":4.1,"npi":[1710908504]}]}]},{"tin":{"type":"ein","value":"261512163"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":360.54,"providers":[{"billed_charge":0,"npi":[1740450121]}]},{"allowed_amount":354.73,"providers":[{"billed_charge":0,"npi":[1740450121]},{"billed_charge":354.73,"npi":[1740450121]},{"billed_charge":248.31,"npi":[1740450121]},{"billed_charge":215.7,"npi":[1740450121]}]}]}]},{"name":"TX/PRO/DX INJ NEW DRUG ADDON","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96375","description":"TX/PRO/DX INJ NEW DRUG ADDON","allowed_amounts":[{"tin":{"type":"ein","value":"852713042"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":39.72,"providers":[{"billed_charge":0,"npi":[1376141556]}]},{"allowed_amount":440.47,"providers":[{"billed_charge":440.47,"npi":[1376141556]},{"billed_charge":0,"npi":[1376141556]}]},{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1376141556]}]},{"allowed_amount":293.65,"providers":[{"billed_charge":293.65,"npi":[1376141556]},{"billed_charge":0,"npi":[1376141556]},{"billed_charge":263.65,"npi":[1376141556]}]},{"allowed_amount":176.4,"providers":[{"billed_charge":0,"npi":[1376141556]}]},{"allowed_amount":12.06,"providers":[{"billed_charge":0,"npi":[1376141556]}]},{"allowed_amount":146.82,"providers":[{"billed_charge":0,"npi":[1376141556]},{"billed_charge":146.82,"npi":[1376141556]}]},{"allowed_amount":587.29,"providers":[{"billed_charge":587.29,"npi":[1376141556]},{"billed_charge":0,"npi":[1376141556]}]}]},{"tin":{"type":"ein","value":"834546114"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1972258580]}]},{"allowed_amount":122.3,"providers":[{"billed_charge":0,"npi":[1972258580]}]},{"allowed_amount":61.15,"providers":[{"billed_charge":0,"npi":[1972258580]}]},{"allowed_amount":179.87,"providers":[{"billed_charge":0,"npi":[1972258580]}]},{"allowed_amount":59.96,"providers":[{"billed_charge":0,"npi":[1972258580]},{"billed_charge":59.96,"npi":[1972258580]}]},{"allowed_amount":119.91,"providers":[{"billed_charge":119.91,"npi":[1972258580]},{"billed_charge":0,"npi":[1972258580]}]},{"allowed_amount":299.78,"providers":[{"billed_charge":0,"npi":[1972258580]}]}]},{"tin":{"type":"ein","value":"882501936"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1750013769]}]},{"allowed_amount":538.56,"providers":[{"billed_charge":538.56,"npi":[1750013769]},{"billed_charge":0,"npi":[1750013769]}]},{"allowed_amount":269.28,"pro