{"reporting_entity_name":"Community Health Choice, Inc","reporting_entity_type":"Group Health Plan","plan_name":"Community Ultra Select Gold Marketplace","plan_id_type":"HIOS","plan_id":"PEPGM0000000047","plan_market_type":"Individual","last_updated_on":"2026-07-14","out_of_network":[{"name":"SBSQ HOSP IP/OBS MODERATE 35","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":"760459500"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":87.12,"providers":[{"billed_charge":87.12,"npi":[1114644366]}]},{"allowed_amount":82.78,"providers":[{"billed_charge":82.78,"npi":[1104408145]}]},{"allowed_amount":75.93,"providers":[{"billed_charge":0,"npi":[1265069322,1356865208,1578921243]},{"billed_charge":75.93,"npi":[1457914517,1174887285,1396307963]}]},{"allowed_amount":64.53,"providers":[{"billed_charge":0,"npi":[1184479420,1932972304]}]},{"allowed_amount":76.3,"providers":[{"billed_charge":0,"npi":[1396204228]}]},{"allowed_amount":73.63,"providers":[{"billed_charge":73.63,"npi":[1538556402]}]}]},{"tin":{"type":"ein","value":"741613878"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":82.78,"providers":[{"billed_charge":82.78,"npi":[1003047457]}]},{"allowed_amount":75.93,"providers":[{"billed_charge":0,"npi":[1881989440,1710247754]},{"billed_charge":75.93,"npi":[1679078042,1114036373,1073848396]}]},{"allowed_amount":76.3,"providers":[{"billed_charge":76.3,"npi":[1366869240,1265483531,1174886782]}]}]},{"tin":{"type":"ein","value":"844058518"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":75.93,"providers":[{"billed_charge":75.93,"npi":[1932470689]}]},{"allowed_amount":76.3,"providers":[{"billed_charge":76.3,"npi":[1932470689]}]}]}]},{"name":"MED LIST DOCD IN RCRD","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"1159F","description":"MED LIST DOCD IN RCRD","allowed_amounts":[{"tin":{"type":"ein","value":"204923281"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1851532444,1922056357,1407878879,1861625444,1841363140,1306343223,1164840492,1265892525,1346860277,1235685223,1093115081,1164086500,1982076956]}]}]}]},{"name":"EMERGENCY DEPT VISIT MOD MDM","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99284","description":"EMERGENCY DEPT VISIT MOD MDM","allowed_amounts":[{"tin":{"type":"ein","value":"844504483"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":127.66,"providers":[{"billed_charge":127.66,"npi":[1821482357]}]},{"allowed_amount":120.55,"providers":[{"billed_charge":120.55,"npi":[1023438264]}]},{"allowed_amount":129.42,"providers":[{"billed_charge":0,"npi":[1417216052,1033567201,1740429208,1689878340,1578880282,1205062262,1346419488,1821330044,1912004797,1164876298]},{"billed_charge":129.42,"npi":[1184982043,1245764661,1386674778,1205062262,1891809083,1942415724]}]},{"allowed_amount":122.16,"providers":[{"billed_charge":0,"npi":[1396095774,1902434046,1578208633,1255542197]}]}]},{"tin":{"type":"ein","value":"922417967"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":127.66,"providers":[{"billed_charge":0,"npi":[1487753638]}]},{"allowed_amount":110.01,"providers":[{"billed_charge":110.01,"npi":[1821535261,1346880028]},{"billed_charge":0,"npi":[1578221917,1003424284,1538521133]}]},{"allowed_amount":129.42,"providers":[{"billed_charge":0,"npi":[1386087815,1649685058,1588674097,1346879749,1346483799,1457774788,1104218197,1932369410,1881826311,1366857278,1275152977,1740770759,1346225018,1851913669,1578067740]},{"billed_charge":129.42,"npi":[1437387255]}]},{"allowed_amount":130.07,"providers":[{"billed_charge":0,"npi":[1891105714]}]},{"allowed_amount":122.16,"providers":[{"billed_charge":0,"npi":[1205414125,1124288998]}]},{"allowed_amount":122.07,"providers":[{"billed_charge":0,"npi":[1952808495]}]}]}]},{"name":"EMERGENCY DEPT VISIT HI MDM","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99285","description":"EMERGENCY DEPT VISIT HI MDM","allowed_amounts":[{"tin":{"type":"ein","value":"742501542"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":185.25,"providers":[{"billed_charge":185.25,"npi":[1679149066,1316680333,1396109609]},{"billed_charge":0,"npi":[1316680333]}]},{"allowed_amount":157.47,"providers":[{"billed_charge":157.47,"npi":[1558873349]}]},{"allowed_amount":187.2,"providers":[{"billed_charge":1.95,"npi":[1316680333]},{"billed_charge":187.2,"npi":[1316680333,1215676267,1952807729,1306061262,1376701904,1528695384,1538722913,1851582464,1730321860,1154694529]},{"billed_charge":0,"npi":[1720020373,1023351756,1851582464,1275513426,1265051361,1346821741]},{"billed_charge":89.8,"npi":[1225290091]}]},{"allowed_amount":159.13,"providers":[{"billed_charge":0,"npi":[1518499672,1336884014,1770897191,1205067048,1972735223,1982044210,1710483490,1437637386]},{"billed_charge":159.13,"npi":[1891156550,1003459108]}]},{"allowed_amount":178.01,"providers":[{"billed_charge":178.01,"npi":[1952805483]}]},{"allowed_amount":177.11,"providers":[{"billed_charge":177.11,"npi":[1417452897]}]}]},{"tin":{"type":"ein","value":"844504483"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":185.25,"providers":[{"billed_charge":185.25,"npi":[1730574625]},{"billed_charge":0,"npi":[1497074991,1881974202]}]},{"allowed_amount":187.2,"providers":[{"billed_charge":187.2,"npi":[1720279748,1164926143,1942645932,1174058366,1245764661,1033567201,1194080507,1396189536,1548687080,1760879829,1881883080,1881919793,1891182168,1164876298,1063856235,1326149931,1467614925,1205853892]},{"billed_charge":0,"npi":[1124289053,1922637842,1881155679,1245812486,1033852611,1942610431,1316443229,1942415724,1255837381,1437310562,1821330044,1730574625,1750798351,1902052038,1174058366]},{"billed_charge":15.74,"npi":[1255837381]},{"billed_charge":53.31,"npi":[1750798351]}]},{"allowed_amount":177.11,"providers":[{"billed_charge":177.11,"npi":[1083941819,1255542197,1245593573,1528327012,1568882355,1932545183,1619363413,1518100064]},{"billed_charge":0,"npi":[1346982444,1568882355,1902434046,1083000111,1659729333,1033345855,1083941819]}]},{"allowed_amount":178.01,"providers":[{"billed_charge":178.01,"npi":[1013365295,1902429632]},{"billed_charge":0,"npi":[1013365295,1114211620]}]},{"allowed_amount":207.63,"providers":[{"billed_charge":0,"npi":[1336568203]}]},{"allowed_amount":176.59,"providers":[{"billed_charge":176.59,"npi":[1437771417]}]},{"allowed_amount":150.16,"providers":[{"billed_charge":150.16,"npi":[1467782284]}]}]},{"tin":{"type":"ein","value":"922417967"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":185.25,"providers":[{"billed_charge":70.74,"npi":[1518544485]}]},{"allowed_amount":187.2,"providers":[{"billed_charge":0,"npi":[1518544485,1649759655,1376738286,1205199379,1437319308,1194812669,1508165085,1558948471,1760649651]},{"billed_charge":187.2,"npi":[1164059895,1275528002,1316527880,1326667205,1386218766]}]},{"allowed_amount":159.13,"providers":[{"billed_charge":0,"npi":[1760931562,1053878314,1568117224,1407460686]},{"billed_charge":159.13,"npi":[1578348462]}]},{"allowed_amount":150.56,"providers":[{"billed_charge":0,"npi":[1396506259]}]},{"allowed_amount":151.28,"providers":[{"billed_charge":151.28,"npi":[1326494808]}]}]}]},{"name":"COMPREHEN METABOLIC PANEL","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80053","description":"COMPREHEN METABOLIC PANEL","allowed_amounts":[{"tin":{"type":"ein","value":"760545192"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1871619254,1083937593,1184179194,1629828405]}]}]}]},{"name":"ELECTROCARDIOGRAM TRACING","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"93005","description":"ELECTROCARDIOGRAM TRACING","allowed_amounts":[{"tin":{"type":"ein","value":"760545192"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1871619254,1083937593,1184179194]}]},{"allowed_amount":77.35,"providers":[{"billed_charge":0,"npi":[1083937593]}]}]}]},{"name":"INJ KETOROLAC TROMETHAMINE 15 MG","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J1885","description":"INJ KETOROLAC TROMETHAMINE 15 MG","allowed_amounts":[{"tin":{"type":"ein","value":"760545192"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0.79,"providers":[{"billed_charge":0.79,"npi":[1871619254]}]},{"allowed_amount":0.87,"providers":[{"billed_charge":0,"npi":[1871619254,1184179194,1083937593]},{"billed_charge":0.87,"npi":[1083937593]}]},{"allowed_amount":0.88,"providers":[{"billed_charge":0,"npi":[1871619254]},{"billed_charge":0.88,"npi":[1629828405]}]},{"allowed_amount":0.44,"providers":[{"billed_charge":0.44,"npi":[1871619254,1629828405]},{"billed_charge":0,"npi":[1629828405]}]}]}]},{"name":"URINALYSIS AUTO W/SCOPE","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81001","description":"URINALYSIS AUTO W/SCOPE","allowed_amounts":[{"tin":{"type":"ein","value":"760545192"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1083937593,1871619254,1629828405]}]}]}]},{"name":"COMPLETE CBC W/AUTO DIFF WBC","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":"760545192"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1083937593,1871619254,1184179194,1629828405]}]}]}]},{"name":"X-RAY EXAM CHEST 1 VIEW","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":"741680498"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":9.06,"providers":[{"billed_charge":9.06,"npi":[1851689897,1700132842]},{"billed_charge":0,"npi":[1467696633]}]},{"allowed_amount":8.86,"providers":[{"billed_charge":0,"npi":[1225472392]}]},{"allowed_amount":8.94,"providers":[{"billed_charge":8.94,"npi":[1073777249,1467609438,1720064652,1912972258,1467440594,1306827472,1467440941,1427068063,1134483738,1225472392]},{"billed_charge":0,"npi":[1760439129,1851689897,1740361039,1437655834,1356359335,1871511741,1326545690,1841287018,1326242983,1679557821,1184116253,1467440941,1346237401,1992745814,1528007606,1174666994,1467440594,1720064652,1245454693,1215181177,1740710169,1437440492]}]},{"allowed_amount":8.52,"providers":[{"billed_charge":0,"npi":[1194748251]}]},{"allowed_amount":8.98,"providers":[{"billed_charge":8.98,"npi":[1760434955,1245454693]},{"billed_charge":0,"npi":[1245454693]}]},{"allowed_amount":8.75,"providers":[{"billed_charge":8.75,"npi":[1609166735]}]},{"allowed_amount":8.73,"providers":[{"billed_charge":0,"npi":[1356359335,1326242983]}]},{"allowed_amount":8.47,"providers":[{"billed_charge":8.47,"npi":[1477968584]}]},{"allowed_amount":8.63,"providers":[{"billed_charge":0,"npi":[1275988719,1871726687]},{"billed_charge":8.63,"npi":[1811109895]}]}]}]},{"name":"OFFICE O/P EST MOD 30 MIN","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":"741613878"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":101.58,"providers":[{"billed_charge":86.58,"npi":[1659460277,1033359823]}]},{"allowed_amount":86.34,"providers":[{"billed_charge":56.34,"npi":[1063511798]},{"billed_charge":71.34,"npi":[1285821355]}]},{"allowed_amount":91,"providers":[{"billed_charge":61,"npi":[1225410244,1306080460,1720168156,1912580895,1073641007,1225248453,1497109367,1881153609,1124332192,1508210543,1275752503,1144632175,1578839924,1700231099,1932586948]},{"billed_charge":76,"npi":[1629167093,1427231778,1366510018,1710481817,1396750881,1700950748,1134362692,1134318611,1306454392,1558674705,1386687291,1467871541,1700956505,1437478575,1609032531,1588027411,1700049467,1023396306]},{"billed_charge":31,"npi":[1235591389]}]},{"allowed_amount":77.74,"providers":[{"billed_charge":17.74,"npi":[1598544777]},{"billed_charge":47.74,"npi":[1720315534]}]},{"allowed_amount":91.46,"providers":[{"billed_charge":61.46,"npi":[1790171957,1396887535,1003047457]},{"billed_charge":76.46,"npi":[1396887535,1730539289]}]},{"allowed_amount":77.35,"providers":[{"billed_charge":47.35,"npi":[1063511798]},{"billed_charge":62.35,"npi":[1255756318]},{"billed_charge":17.35,"npi":[1821227505]}]}]},{"tin":{"type":"ein","value":"371829497"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":141.59,"providers":[{"billed_charge":111.59,"npi":[1093251860]},{"billed_charge":96.59,"npi":[1093251860]}]}]}]},{"name":"CT ABD & PELVIS W/CONTRAST","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"74177","description":"CT ABD & PELVIS W/CONTRAST","allowed_amounts":[{"tin":{"type":"ein","value":"741680498"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":89.95,"providers":[{"billed_charge":0,"npi":[1629235064,1437440492,1326545690]}]},{"allowed_amount":86.53,"providers":[{"billed_charge":86.53,"npi":[1700132842]},{"billed_charge":0,"npi":[1932334117,1912172594]}]},{"allowed_amount":89.82,"providers":[{"billed_charge":0,"npi":[1700132842,1215231964,1740361039,1841789781,1629235064,1285053975,1033311782,1366708000,1134483738]},{"billed_charge":89.82,"npi":[1003343492,1427254457,1912172594,1417240755,1376530444,1437440492,1427098029,1538185046]}]},{"allowed_amount":87.48,"providers":[{"billed_charge":0,"npi":[1427254457]},{"billed_charge":87.48,"npi":[1285053546]}]},{"allowed_amount":87.71,"providers":[{"billed_charge":0,"npi":[1629235064]}]},{"allowed_amount":90.27,"providers":[{"billed_charge":90.27,"npi":[1790776771]}]},{"allowed_amount":84.85,"providers":[{"billed_charge":84.85,"npi":[1477968584]}]}]}]},{"name":"SBSQ HOSP IP/OBS HIGH 50","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99233","description":"SBSQ HOSP IP/OBS HIGH 50","allowed_amounts":[{"tin":{"type":"ein","value":"204923281"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":123.15,"providers":[{"billed_charge":123.15,"npi":[1124443288,1437508074]}]},{"allowed_amount":115.7,"providers":[{"billed_charge":115.7,"npi":[1881821775,1083058515,1912401977,1679147003,1336300516,1558980037]}]},{"allowed_amount":115.12,"providers":[{"billed_charge":0,"npi":[1700469335,1902252349,1649641226]},{"billed_charge":115.12,"npi":[1902252349,1457097198,1225349061,1659729028]}]},{"allowed_amount":110.5,"providers":[{"billed_charge":0,"npi":[1437310083]}]}]},{"tin":{"type":"ein","value":"741613878"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":115.7,"providers":[{"billed_charge":0,"npi":[1538696224,1053491324]},{"billed_charge":115.7,"npi":[1366869240,1174886782]}]},{"allowed_amount":115.12,"providers":[{"billed_charge":0,"npi":[1881989440,1073255758,1821403775]},{"billed_charge":21.81,"npi":[1710247754]},{"billed_charge":115.12,"npi":[1336229764,1154852895]}]}]},{"tin":{"type":"ein","value":"332241086"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":115.7,"providers":[{"billed_charge":115.7,"npi":[1275889198,1669768297,1982915013,1073773701,1124222799]}]},{"allowed_amount":115.12,"providers":[{"billed_charge":115.12,"npi":[1649421934,1053760660,1710240098,1457884082,1124423751,1073773701,1861874000,1164726998,1134323462,1124222799,1164843553,1588009815]},{"billed_charge":0,"npi":[1003041443,1720076938]}]},{"allowed_amount":111.06,"providers":[{"billed_charge":0,"npi":[1952511545]}]},{"allowed_amount":97.85,"providers":[{"billed_charge":97.85,"npi":[1659964591,1669552071]}]}]}]},{"name":"HOSP IP/OBS DSCHRG MGMT >30","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":"204923281"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":119.51,"providers":[{"billed_charge":119.51,"npi":[1124443288]},{"billed_charge":0,"npi":[1598172975]}]},{"allowed_amount":114.94,"providers":[{"billed_charge":114.94,"npi":[1215076229,1083058515,1912401977,1154515625,1699091835,1558980037,1043714447]},{"billed_charge":0,"npi":[1376925081]}]},{"allowed_amount":109.76,"providers":[{"billed_charge":109.76,"npi":[1942688023]},{"billed_charge":0,"npi":[1437310083]}]},{"allowed_amount":114.38,"providers":[{"billed_charge":114.38,"npi":[1902252349,1215101464,1225349061,1336300516,1326402876,1659729028,1548494016,1902434616]},{"billed_charge":0,"npi":[1316399769]}]},{"allowed_amount":110.3,"providers":[{"billed_charge":110.3,"npi":[1740634997]}]}]}]},{"name":"SERVICES PROV AN URGENT CARE CENTER","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"S9088","description":"SERVICES PROV AN URGENT CARE CENTER","allowed_amounts":[{"tin":{"type":"ein","value":"824436036"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":30,"providers":[{"billed_charge":30,"npi":[1609370022,1114492618]},{"billed_charge":0,"npi":[1114492618,1609370022]},{"billed_charge":27.62,"npi":[1114492618]},{"billed_charge":9.81,"npi":[1609370022]}]}]}]},{"name":"OFFICE O/P EST LOW 20 MIN","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":"824436036"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":95.55,"providers":[{"billed_charge":65.55,"npi":[1609370022]}]},{"allowed_amount":81.22,"providers":[{"billed_charge":51.22,"npi":[1114492618]},{"billed_charge":81.22,"npi":[1114492618]}]},{"allowed_amount":101.15,"providers":[{"billed_charge":71.15,"npi":[1609370022]},{"billed_charge":101.15,"npi":[1609370022]},{"billed_charge":56.15,"npi":[1609370022]}]},{"allowed_amount":85.97,"providers":[{"billed_charge":55.97,"npi":[1114492618]}]}]},{"tin":{"type":"ein","value":"741613878"},"billing_class":"PROFESSIONAL","payments":[{"allowed_amount":68.97,"providers":[{"billed_charge":38.97,"npi":[1053808485]}]},{"allowed_amount":61.79,"providers":[{"billed_charge":46.79,"npi":[1700950748,1700049467,1063687663,1104065135,1720168156,1124024252,1659460277,1841444544,1366070211]},{"billed_charge":31.79,"npi":[1497109367,1043960099,1063687663,1568924447,1306454392,1659304699,1861572281,1811077241,1730539289]},{"billed_charge":1.79,"npi":[1073641007,1417152752,1568924447]},{"billed_charge":61.79,"npi":[1740545813]}]},{"allowed_amount":52.52,"providers":[{"billed_charge":22.52,"npi":[1134466741,1295244804,1063511798]},{"billed_charge":37.52,"npi":[1578012852,1407094667]}]},{"allowed_amount":62.1,"providers":[{"billed_charge":32.1,"npi":[1578839924,1457499071,1235592361]},{"billed_charge":47.1,"npi":[1144632175]}]}]}]},{"name":"ASSAY OF TROPONIN QUANT","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84484","description":"ASSAY OF TROPONIN QUANT","allowed_amounts":[{"tin":{"type":"ein","value":"760545192"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1083937593,1871619254,1184179194]}]}]}]},{"name":"LOCM 300-399 MG/ML I CONC PER ML","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"Q9967","description":"LOCM 300-399 MG/ML I CONC PER ML","allowed_amounts":[{"tin":{"type":"ein","value":"760545192"},"billing_class":"INSTITUTIONAL","payments":[{"allowed_amount":0,"providers":[{"billed_charge":0,"npi":[1871619254,1184179194,1083937593,1629828405]}]}]}]}]}
