{"reporting_entity_name": "Molina-Healthcare-of-New-Mexico", "reporting_entity_type": "health insurance issuer", "last_updated_on": "2026-08-21", "version": "2.0.0", "out_of_network": [{"name": "Hemodialysis - Outpatient or Home - Hemodialysis/Composite o", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0821", "description": "Hemodialysis - Outpatient or Home", "allowed_amounts": [{"tin": {"type": "ein", "value": "822857014"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 446.0, "billing_code_modifier": ["G5V7"], "providers": [{"billed_charge": 8832.0, "npi": [1194229096]}]}, {"allowed_amount": 1947.24, "billing_code_modifier": ["G5V7"], "providers": [{"billed_charge": 8832.0, "npi": [1194229096]}]}, {"allowed_amount": 445.94, "billing_code_modifier": ["G4V7"], "providers": [{"billed_charge": 8832.0, "npi": [1194229096]}]}, {"allowed_amount": 445.94, "billing_code_modifier": ["G5V7"], "providers": [{"billed_charge": 8832.0, "npi": [1194229096]}]}, {"allowed_amount": 444.84, "billing_code_modifier": ["G5V7"], "providers": [{"billed_charge": 8832.0, "npi": [1194229096]}]}]}]}, {"name": "Emergency Room - General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0450", "description": "EMERGENCY ROOM", "allowed_amounts": [{"tin": {"type": "ein", "value": "742499952"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": ["ER"], "providers": [{"billed_charge": 7192.0, "npi": [1770536120]}]}, {"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 11916.0, "npi": [1770536120]}, {"billed_charge": 7192.0, "npi": [1770536120]}, {"billed_charge": 4587.0, "npi": [1770536120]}]}, {"allowed_amount": 455.69, "billing_code_modifier": [""], "providers": [{"billed_charge": 7192.0, "npi": [1770536120]}, {"billed_charge": 4587.0, "npi": [1770536120]}]}, {"allowed_amount": 180.38, "billing_code_modifier": [""], "providers": [{"billed_charge": 2203.0, "npi": [1770536120]}]}, {"allowed_amount": 892.62, "billing_code_modifier": ["25"], "providers": [{"billed_charge": 7192.0, "npi": [1770536120]}]}, {"allowed_amount": 583.94, "billing_code_modifier": [""], "providers": [{"billed_charge": 4587.0, "npi": [1770536120]}]}, {"allowed_amount": 256.33, "billing_code_modifier": [""], "providers": [{"billed_charge": 4587.0, "npi": [1770536120]}]}, {"allowed_amount": 696.57, "billing_code_modifier": ["25"], "providers": [{"billed_charge": 7191.0, "npi": [1770536120]}]}, {"allowed_amount": 328.47, "billing_code_modifier": [""], "providers": [{"billed_charge": 4587.0, "npi": [1770536120]}]}]}]}, {"name": "PAIN SEVERITY QUANTIFIED NO PAIN PRESENT", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "1126F", "description": "PAIN SEVERITY QUANTIFIED NO PAIN PRESENT", "allowed_amounts": [{"tin": {"type": "ein", "value": "237429653"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 0.01, "npi": [1831617265]}]}]}]}, {"name": "Pharmacy - Extension of 25X - Drug Requiring Detailed Coding", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0636", "description": "Pharmacy - Extension of 25x", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.67, "billing_code_modifier": [""], "providers": [{"billed_charge": 9.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 34.0, "npi": [1760020044]}, {"billed_charge": 288.0, "npi": [1760020044]}, {"billed_charge": 19.75, "npi": [1760020044]}, {"billed_charge": 19.0, "npi": [1760020044]}, {"billed_charge": 67.0, "npi": [1760020044]}, {"billed_charge": 57.5, "npi": [1760020044]}, {"billed_charge": 28.0, "npi": [1760020044]}, {"billed_charge": 30.0, "npi": [1760020044]}, {"billed_charge": 107.4, "npi": [1760020044]}, {"billed_charge": 2.0, "npi": [1760020044]}, {"billed_charge": 0.72, "npi": [1760020044]}, {"billed_charge": 3.0, "npi": [1760020044]}, {"billed_charge": 18.0, "npi": [1760020044]}, {"billed_charge": 31.0, "npi": [1760020044]}, {"billed_charge": 12.0, "npi": [1760020044]}, {"billed_charge": 1.2, "npi": [1760020044]}, {"billed_charge": 2.88, "npi": [1760020044]}, {"billed_charge": 15.0, "npi": [1760020044]}, {"billed_charge": 4.5, "npi": [1760020044]}, {"billed_charge": 234.0, "npi": [1760020044]}, {"billed_charge": 96.0, "npi": [1760020044]}, {"billed_charge": 268.0, "npi": [1760020044]}, {"billed_charge": 19.5, "npi": [1760020044]}, {"billed_charge": 14.8333, "npi": [1760020044]}, {"billed_charge": 5.7941, "npi": [1760020044]}, {"billed_charge": 529.0, "npi": [1760020044]}, {"billed_charge": 35.0, "npi": [1760020044]}, {"billed_charge": 44.0, "npi": [1760020044]}, {"billed_charge": 263.0, "npi": [1760020044]}, {"billed_charge": 5.87, "npi": [1760020044]}, {"billed_charge": 14.0, "npi": [1760020044]}, {"billed_charge": 56.0, "npi": [1760020044]}, {"billed_charge": 59.0, "npi": [1760020044]}, {"billed_charge": 27.6667, "npi": [1760020044]}]}, {"allowed_amount": 0.66, "billing_code_modifier": [""], "providers": [{"billed_charge": 6.0, "npi": [1760020044]}, {"billed_charge": 9.0, "npi": [1760020044]}]}]}]}, {"name": "EKG/ECG (Electrocardiogram) - General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0730", "description": "EKG/ECG (ELECTROCARDIOGRAM)", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 187.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["76"], "providers": [{"billed_charge": 187.0, "npi": [1760020044]}]}]}]}, {"name": "Laboratory - Chemistry", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0301", "description": "LABORATORY", "allowed_amounts": [{"tin": {"type": "ein", "value": "751362671"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 185.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 235.0, "npi": [1821025990]}]}, {"allowed_amount": 64.55, "billing_code_modifier": ["90"], "providers": [{"billed_charge": 82.0, "npi": [1821025990]}]}, {"allowed_amount": 37.79, "billing_code_modifier": [""], "providers": [{"billed_charge": 48.0, "npi": [1821025990]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["9091GZ"], "providers": [{"billed_charge": 235.0, "npi": [1821025990]}]}]}]}, {"name": "Laboratory - Nonroutine Dialysis", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0304", "description": "LABORATORY", "allowed_amounts": [{"tin": {"type": "ein", "value": "822857014"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 595.51, "npi": [1194229096]}, {"billed_charge": 223.61, "npi": [1194229096]}, {"billed_charge": 1805.83, "npi": [1194229096]}, {"billed_charge": 806.49, "npi": [1194229096]}, {"billed_charge": 131.58, "npi": [1194229096]}, {"billed_charge": 172.38, "npi": [1194229096]}, {"billed_charge": 225.19, "npi": [1194229096]}, {"billed_charge": 216.65, "npi": [1194229096]}, {"billed_charge": 207.5, "npi": [1194229096]}, {"billed_charge": 1113.87, "npi": [1194229096]}, {"billed_charge": 103.43, "npi": [1194229096]}, {"billed_charge": 160.34, "npi": [1194229096]}, {"billed_charge": 111.15, "npi": [1194229096]}, {"billed_charge": 382.04, "npi": [1194229096]}, {"billed_charge": 200.81, "npi": [1194229096]}, {"billed_charge": 226.18, "npi": [1194229096]}, {"billed_charge": 424.43, "npi": [1194229096]}, {"billed_charge": 283.07, "npi": [1194229096]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["91"], "providers": [{"billed_charge": 172.38, "npi": [1194229096]}]}]}]}, {"name": "Pharmacy - Extension of 25X - Drug Requiring Detailed Coding", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0636", "description": "Pharmacy - Extension of 25x", "allowed_amounts": [{"tin": {"type": "ein", "value": "863385534"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 32.53, "npi": [1689370595]}, {"billed_charge": 9.2, "npi": [1689370595]}, {"billed_charge": 19.38, "npi": [1689370595]}, {"billed_charge": 21.39, "npi": [1689370595]}, {"billed_charge": 1.29, "npi": [1689370595]}, {"billed_charge": 3.91, "npi": [1689370595]}, {"billed_charge": 96.16, "npi": [1689370595]}, {"billed_charge": 11.25, "npi": [1689370595]}, {"billed_charge": 56.19, "npi": [1689370595]}, {"billed_charge": 80.63, "npi": [1689370595]}, {"billed_charge": 4.28, "npi": [1689370595]}, {"billed_charge": 31.33, "npi": [1689370595]}, {"billed_charge": 292.77, "npi": [1689370595]}, {"billed_charge": 6.24, "npi": [1689370595]}, {"billed_charge": 3.19, "npi": [1689370595]}]}]}]}, {"name": "CT Scan - General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0350", "description": "CT SCAN", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 466.48, "billing_code_modifier": [""], "providers": [{"billed_charge": 795.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 383.0, "npi": [1760020044]}, {"billed_charge": 708.5, "npi": [1760020044]}, {"billed_charge": 622.0, "npi": [1760020044]}, {"billed_charge": 1123.0, "npi": [1760020044]}, {"billed_charge": 1303.0, "npi": [1760020044]}]}, {"allowed_amount": 682.07, "billing_code_modifier": [""], "providers": [{"billed_charge": 1303.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["XU"], "providers": [{"billed_charge": 383.0, "npi": [1760020044]}]}, {"allowed_amount": 342.92, "billing_code_modifier": [""], "providers": [{"billed_charge": 622.0, "npi": [1760020044]}]}, {"allowed_amount": 839.89, "billing_code_modifier": [""], "providers": [{"billed_charge": 622.0, "npi": [1760020044]}, {"billed_charge": 795.0, "npi": [1760020044]}]}, {"allowed_amount": 432.61, "billing_code_modifier": [""], "providers": [{"billed_charge": 383.0, "npi": [1760020044]}]}]}]}, {"name": "US BREAST UNI REAL TIME WITH IMAGE LIMITED", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "76642", "description": "US BREAST UNI REAL TIME WITH IMAGE LIMITED", "allowed_amounts": [{"tin": {"type": "ein", "value": "822135009"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 35.65, "billing_code_modifier": ["26LT"], "providers": [{"billed_charge": 517.0, "npi": [1639305378]}]}, {"allowed_amount": 53.48, "billing_code_modifier": ["2650"], "providers": [{"billed_charge": 1034.0, "npi": [1639305378]}]}, {"allowed_amount": 35.65, "billing_code_modifier": ["26RT"], "providers": [{"billed_charge": 517.0, "npi": [1639305378]}]}]}]}, {"name": "PSYCHOTHERAPY W/PATIENT 60 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "90837", "description": "PSYCHOTHERAPY W/PATIENT 60 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "261486393"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 188.38, "billing_code_modifier": ["U7"], "providers": [{"billed_charge": 220.66, "npi": [1154853497]}, {"billed_charge": 230.0, "npi": [1154853497]}]}, {"allowed_amount": 188.38, "billing_code_modifier": [""], "providers": [{"billed_charge": 220.66, "npi": [1154853497]}, {"billed_charge": 230.0, "npi": [1154853497]}]}, {"allowed_amount": 188.38, "billing_code_modifier": ["XU"], "providers": [{"billed_charge": 220.66, "npi": [1154853497]}]}]}]}, {"name": "Laboratory - Bacteriology & Microbiology", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0306", "description": "LABORATORY", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 67.0, "npi": [1760020044]}, {"billed_charge": 28.0, "npi": [1760020044]}, {"billed_charge": 29.0, "npi": [1760020044]}, {"billed_charge": 30.0, "npi": [1760020044]}, {"billed_charge": 45.6667, "npi": [1760020044]}, {"billed_charge": 61.0, "npi": [1760020044]}, {"billed_charge": 38.0, "npi": [1760020044]}, {"billed_charge": 16.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["91"], "providers": [{"billed_charge": 38.0, "npi": [1760020044]}]}]}]}, {"name": "Pharmacy - General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0250", "description": "PHARMACY (ALSO SEE 063X, AN EXTENSION OF 025X)", "allowed_amounts": [{"tin": {"type": "ein", "value": "822857014"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 5.69, "npi": [1194229096]}, {"billed_charge": 99.3, "npi": [1194229096]}, {"billed_charge": 55.55, "npi": [1194229096]}]}]}]}, {"name": "BODY MASS INDEX DOCUMENTED", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "3008F", "description": "BODY MASS INDEX DOCUMENTED", "allowed_amounts": [{"tin": {"type": "ein", "value": "237429653"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 0.01, "npi": [1831617265]}]}]}]}, {"name": "IV Therapy -General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0260", "description": "IV THERAPY", "allowed_amounts": [{"tin": {"type": "ein", "value": "751362671"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 643.18, "billing_code_modifier": [""], "providers": [{"billed_charge": 817.0, "npi": [1821025990]}]}, {"allowed_amount": 142.495, "billing_code_modifier": [""], "providers": [{"billed_charge": 181.0, "npi": [1821025990]}]}, {"allowed_amount": 210.99, "billing_code_modifier": [""], "providers": [{"billed_charge": 268.0, "npi": [1821025990]}]}, {"allowed_amount": 142.49, "billing_code_modifier": [""], "providers": [{"billed_charge": 181.0, "npi": [1821025990]}]}, {"allowed_amount": 142.4913, "billing_code_modifier": [""], "providers": [{"billed_charge": 181.0, "npi": [1821025990]}]}, {"allowed_amount": 142.48, "billing_code_modifier": [""], "providers": [{"billed_charge": 181.0, "npi": [1821025990]}]}, {"allowed_amount": 142.491, "billing_code_modifier": [""], "providers": [{"billed_charge": 181.0, "npi": [1821025990]}]}]}]}, {"name": "MEDICATION LIST DOCUMENTED IN MEDICAL RECORD", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "1159F", "description": "MEDICATION LIST DOCUMENTED IN MEDICAL RECORD", "allowed_amounts": [{"tin": {"type": "ein", "value": "237429653"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 0.01, "npi": [1831617265]}]}]}]}, {"name": "Pharmacy - General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0250", "description": "PHARMACY (ALSO SEE 063X, AN EXTENSION OF 025X)", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 43.0, "npi": [1760020044]}, {"billed_charge": 92.0, "npi": [1760020044]}, {"billed_charge": 10.0, "npi": [1760020044]}, {"billed_charge": 7.0, "npi": [1760020044]}, {"billed_charge": 15.0275, "npi": [1760020044]}, {"billed_charge": 25.3924, "npi": [1760020044]}, {"billed_charge": 19.0, "npi": [1760020044]}, {"billed_charge": 5.7188, "npi": [1760020044]}, {"billed_charge": 5.0, "npi": [1760020044]}, {"billed_charge": 26.5152, "npi": [1760020044]}, {"billed_charge": 2.0, "npi": [1760020044]}, {"billed_charge": 21.0, "npi": [1760020044]}, {"billed_charge": 600.0, "npi": [1760020044]}, {"billed_charge": 290.0, "npi": [1760020044]}, {"billed_charge": 606.0, "npi": [1760020044]}, {"billed_charge": 124.0, "npi": [1760020044]}, {"billed_charge": 24.5172, "npi": [1760020044]}, {"billed_charge": 62.0, "npi": [1760020044]}]}]}]}, {"name": "GROUND MILEAGE PER STATUTE MILE", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "A0425", "description": "GROUND MILEAGE PER STATUTE MILE", "allowed_amounts": [{"tin": {"type": "ein", "value": "752474011"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 12.75, "billing_code_modifier": ["NH"], "providers": [{"billed_charge": 12.75, "npi": [1962437855]}]}, {"allowed_amount": 12.75, "billing_code_modifier": ["PH"], "providers": [{"billed_charge": 12.75, "npi": [1962437855]}]}, {"allowed_amount": 11.0, "billing_code_modifier": ["IH"], "providers": [{"billed_charge": 11.0, "npi": [1962437855]}]}, {"allowed_amount": 11.0, "billing_code_modifier": ["HH"], "providers": [{"billed_charge": 11.0, "npi": [1962437855]}]}, {"allowed_amount": 12.75, "billing_code_modifier": ["RH"], "providers": [{"billed_charge": 12.75, "npi": [1962437855]}]}, {"allowed_amount": 12.75, "billing_code_modifier": ["HH"], "providers": [{"billed_charge": 12.75, "npi": [1962437855]}]}, {"allowed_amount": 12.75, "billing_code_modifier": ["HI"], "providers": [{"billed_charge": 12.75, "npi": [1962437855]}]}, {"allowed_amount": 12.75, "billing_code_modifier": ["SH"], "providers": [{"billed_charge": 12.75, "npi": [1962437855]}]}]}]}, {"name": "MOST RECENT SYSTOLIC BLOOD PRESSURE  LT 130 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "3074F", "description": "MOST RECENT SYSTOLIC BLOOD PRESSURE  LT 130 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "237429653"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 0.01, "npi": [1831617265]}]}]}]}, {"name": "Pharmacy - Extension of 25X - Drug Requiring Detailed Coding", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0636", "description": "Pharmacy - Extension of 25x", "allowed_amounts": [{"tin": {"type": "ein", "value": "822857014"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 2.17, "npi": [1194229096]}, {"billed_charge": 154.7, "npi": [1194229096]}, {"billed_charge": 35.14, "npi": [1194229096]}]}]}]}, {"name": "Laboratory - Chemistry", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0301", "description": "LABORATORY", "allowed_amounts": [{"tin": {"type": "ein", "value": "742499952"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 1592.0, "npi": [1770536120]}, {"billed_charge": 1355.0, "npi": [1770536120]}, {"billed_charge": 1554.0, "npi": [1770536120]}, {"billed_charge": 338.0, "npi": [1770536120]}, {"billed_charge": 689.0, "npi": [1770536120]}, {"billed_charge": 2199.0, "npi": [1770536120]}, {"billed_charge": 687.0, "npi": [1770536120]}, {"billed_charge": 1417.0, "npi": [1770536120]}, {"billed_charge": 1299.5833, "npi": [1770536120]}, {"billed_charge": 2078.4286, "npi": [1770536120]}]}]}]}, {"name": "Laboratory - Chemistry", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0301", "description": "LABORATORY", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 39.0, "npi": [1760020044]}, {"billed_charge": 47.0, "npi": [1760020044]}, {"billed_charge": 143.0, "npi": [1760020044]}, {"billed_charge": 28.75, "npi": [1760020044]}, {"billed_charge": 33.5833, "npi": [1760020044]}, {"billed_charge": 45.0, "npi": [1760020044]}, {"billed_charge": 35.0, "npi": [1760020044]}, {"billed_charge": 33.5385, "npi": [1760020044]}, {"billed_charge": 25.0, "npi": [1760020044]}, {"billed_charge": 35.7143, "npi": [1760020044]}, {"billed_charge": 24.0, "npi": [1760020044]}, {"billed_charge": 37.8667, "npi": [1760020044]}]}, {"allowed_amount": 26.38, "billing_code_modifier": [""], "providers": [{"billed_charge": 48.0, "npi": [1760020044]}]}]}]}, {"name": "ALCOHL  AND OR RX SRVC; METHADONE ADMIN  AND OR SERVICE", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "H0020", "description": "ALCOHL  AND OR RX SRVC; METHADONE ADMIN  AND OR SERVICE", "allowed_amounts": [{"tin": {"type": "ein", "value": "742986158"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 21.11, "billing_code_modifier": [""], "providers": [{"billed_charge": 116.0, "npi": [1144437294]}]}]}]}, {"name": "Pharmacy - Extension of 25X - Drug Requiring Detailed Coding", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0636", "description": "Pharmacy - Extension of 25x", "allowed_amounts": [{"tin": {"type": "ein", "value": "932615903"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 15.0, "npi": [1306621982]}, {"billed_charge": 35.12, "npi": [1306621982]}, {"billed_charge": 42.92, "npi": [1306621982]}, {"billed_charge": 115.0, "npi": [1306621982]}, {"billed_charge": 129.0, "npi": [1306621982]}, {"billed_charge": 231.85, "npi": [1306621982]}, {"billed_charge": 30.0, "npi": [1306621982]}, {"billed_charge": 33.6, "npi": [1306621982]}, {"billed_charge": 25.76, "npi": [1306621982]}, {"billed_charge": 24.16, "npi": [1306621982]}, {"billed_charge": 80.0, "npi": [1306621982]}, {"billed_charge": 79.0, "npi": [1306621982]}, {"billed_charge": 32.8, "npi": [1306621982]}]}]}]}, {"name": "SCREENING DIGITAL BREAST TOMOSYNTHESIS BI", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "77063", "description": "SCREENING DIGITAL BREAST TOMOSYNTHESIS BI", "allowed_amounts": [{"tin": {"type": "ein", "value": "822135009"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 31.44, "billing_code_modifier": ["26"], "providers": [{"billed_charge": 213.0, "npi": [1639305378]}]}, {"allowed_amount": 36.91, "billing_code_modifier": ["26"], "providers": [{"billed_charge": 213.0, "npi": [1861663924]}]}]}]}, {"name": "Laboratory - General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0300", "description": "LABORATORY", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 43.0, "npi": [1760020044]}, {"billed_charge": 383.0, "npi": [1760020044]}, {"billed_charge": 22.2, "npi": [1760020044]}, {"billed_charge": 47.0, "npi": [1760020044]}, {"billed_charge": 94.0, "npi": [1760020044]}, {"billed_charge": 54.0, "npi": [1760020044]}, {"billed_charge": 41.0, "npi": [1760020044]}, {"billed_charge": 28.0, "npi": [1760020044]}, {"billed_charge": 30.0, "npi": [1760020044]}, {"billed_charge": 21.0, "npi": [1760020044]}, {"billed_charge": 346.0, "npi": [1760020044]}, {"billed_charge": 26.0, "npi": [1760020044]}, {"billed_charge": 64.0, "npi": [1760020044]}, {"billed_charge": 18.0, "npi": [1760020044]}, {"billed_charge": 31.4545, "npi": [1760020044]}, {"billed_charge": 61.0, "npi": [1760020044]}, {"billed_charge": 13.0, "npi": [1760020044]}, {"billed_charge": 224.0, "npi": [1760020044]}, {"billed_charge": 38.0, "npi": [1760020044]}, {"billed_charge": 15.0, "npi": [1760020044]}, {"billed_charge": 46.2333, "npi": [1760020044]}, {"billed_charge": 16.0, "npi": [1760020044]}, {"billed_charge": 8.0, "npi": [1760020044]}, {"billed_charge": 38.1111, "npi": [1760020044]}, {"billed_charge": 74.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["XU"], "providers": [{"billed_charge": 32.0, "npi": [1760020044]}, {"billed_charge": 30.0, "npi": [1760020044]}, {"billed_charge": 13.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["91"], "providers": [{"billed_charge": 30.0, "npi": [1760020044]}]}, {"allowed_amount": 81.52, "billing_code_modifier": [""], "providers": [{"billed_charge": 143.0, "npi": [1760020044]}]}]}]}, {"name": "ALCOHL  AND OR RX SRVC; METHADONE ADMIN  AND OR SERVICE", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "H0020", "description": "ALCOHL  AND OR RX SRVC; METHADONE ADMIN  AND OR SERVICE", "allowed_amounts": [{"tin": {"type": "ein", "value": "474154443"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 21.11, "billing_code_modifier": [""], "providers": [{"billed_charge": 36.06, "npi": [1568838795]}]}]}]}, {"name": "Laboratory - Hematology", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0305", "description": "LABORATORY", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 28.0, "npi": [1760020044]}, {"billed_charge": 9.0, "npi": [1760020044]}, {"billed_charge": 23.7143, "npi": [1760020044]}, {"billed_charge": 24.8333, "npi": [1760020044]}, {"billed_charge": 25.0, "npi": [1760020044]}]}]}]}, {"name": "SCREENING MAMMOGRAPHY BI 2-VIEW BREAST INC CAD", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "77067", "description": "SCREENING MAMMOGRAPHY BI 2-VIEW BREAST INC CAD", "allowed_amounts": [{"tin": {"type": "ein", "value": "822135009"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 39.78, "billing_code_modifier": ["26"], "providers": [{"billed_charge": 316.0, "npi": [1639305378]}]}, {"allowed_amount": 46.7, "billing_code_modifier": ["26"], "providers": [{"billed_charge": 316.0, "npi": [1861663924]}]}]}]}, {"name": "Pharmacy - Extension of 25X - Drug Requiring Detailed Coding", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0636", "description": "Pharmacy - Extension of 25x", "allowed_amounts": [{"tin": {"type": "ein", "value": "742499952"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": ["ER"], "providers": [{"billed_charge": 3.48, "npi": [1770536120]}]}, {"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 330.0, "npi": [1770536120]}, {"billed_charge": 3.92, "npi": [1770536120]}, {"billed_charge": 102.0, "npi": [1770536120]}, {"billed_charge": 13.5, "npi": [1770536120]}, {"billed_charge": 5.8, "npi": [1770536120]}, {"billed_charge": 14.7538, "npi": [1770536120]}, {"billed_charge": 0.5625, "npi": [1770536120]}, {"billed_charge": 5.25, "npi": [1770536120]}, {"billed_charge": 265.0, "npi": [1770536120]}, {"billed_charge": 4.5, "npi": [1770536120]}, {"billed_charge": 60.0, "npi": [1770536120]}, {"billed_charge": 6.0, "npi": [1770536120]}, {"billed_charge": 144.0, "npi": [1770536120]}, {"billed_charge": 5.7465, "npi": [1770536120]}]}, {"allowed_amount": 0.7125, "billing_code_modifier": [""], "providers": [{"billed_charge": 9.75, "npi": [1770536120]}]}, {"allowed_amount": 0.55, "billing_code_modifier": [""], "providers": [{"billed_charge": 19.5, "npi": [1770536120]}]}, {"allowed_amount": 0.73, "billing_code_modifier": [""], "providers": [{"billed_charge": 19.5, "npi": [1770536120]}]}, {"allowed_amount": 0.55, "billing_code_modifier": ["JW"], "providers": [{"billed_charge": 19.5, "npi": [1770536120]}]}, {"allowed_amount": 0.56, "billing_code_modifier": [""], "providers": [{"billed_charge": 19.5, "npi": [1770536120]}]}, {"allowed_amount": 0.73, "billing_code_modifier": ["JW"], "providers": [{"billed_charge": 19.5, "npi": [1770536120]}]}, {"allowed_amount": 0.555, "billing_code_modifier": [""], "providers": [{"billed_charge": 9.75, "npi": [1770536120]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["JW"], "providers": [{"billed_charge": 3.92, "npi": [1770536120]}, {"billed_charge": 13.5, "npi": [1770536120]}]}, {"allowed_amount": 0.7275, "billing_code_modifier": [""], "providers": [{"billed_charge": 19.5, "npi": [1770536120]}]}]}]}, {"name": "PSYCHOTHERAPY W/PATIENT 60 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "90837", "description": "PSYCHOTHERAPY W/PATIENT 60 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "992340539"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 188.38, "billing_code_modifier": ["U7"], "providers": [{"billed_charge": 250.0, "npi": [1811136047]}]}, {"allowed_amount": 188.38, "billing_code_modifier": [""], "providers": [{"billed_charge": 300.0, "npi": [1811136047]}, {"billed_charge": 250.0, "npi": [1811136047]}]}]}]}, {"name": "BLOOD PRESSURE MEASURED", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "2000F", "description": "BLOOD PRESSURE MEASURED", "allowed_amounts": [{"tin": {"type": "ein", "value": "237429653"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 0.01, "npi": [1831617265]}]}]}]}, {"name": "Emergency Room - General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0450", "description": "EMERGENCY ROOM", "allowed_amounts": [{"tin": {"type": "ein", "value": "852388743"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 300.19, "billing_code_modifier": [""], "providers": [{"billed_charge": 762.0, "npi": [1760020044]}, {"billed_charge": 437.0, "npi": [1760020044]}]}, {"allowed_amount": 1164.31, "billing_code_modifier": ["25"], "providers": [{"billed_charge": 1720.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 67.0, "npi": [1760020044]}, {"billed_charge": 1720.0, "npi": [1760020044]}, {"billed_charge": 302.0, "npi": [1760020044]}, {"billed_charge": 597.0, "npi": [1760020044]}, {"billed_charge": 148.0, "npi": [1760020044]}, {"billed_charge": 652.6667, "npi": [1760020044]}, {"billed_charge": 391.3333, "npi": [1760020044]}, {"billed_charge": 207.0, "npi": [1760020044]}, {"billed_charge": 541.25, "npi": [1760020044]}]}, {"allowed_amount": 415.85, "billing_code_modifier": ["XU"], "providers": [{"billed_charge": 627.0, "npi": [1760020044]}]}, {"allowed_amount": 0.0, "billing_code_modifier": ["XU"], "providers": [{"billed_charge": 207.0, "npi": [1760020044]}]}, {"allowed_amount": 5113.47, "billing_code_modifier": ["25"], "providers": [{"billed_charge": 1201.0, "npi": [1760020044]}]}, {"allowed_amount": 4033.85, "billing_code_modifier": [""], "providers": [{"billed_charge": 6213.0, "npi": [1760020044]}]}, {"allowed_amount": 91.55, "billing_code_modifier": [""], "providers": [{"billed_charge": 130.0, "npi": [1760020044]}]}, {"allowed_amount": 415.85, "billing_code_modifier": [""], "providers": [{"billed_charge": 627.0, "npi": [1760020044]}]}, {"allowed_amount": 815.78, "billing_code_modifier": [""], "providers": [{"billed_charge": 1201.0, "npi": [1760020044]}]}, {"allowed_amount": 533.69, "billing_code_modifier": ["25"], "providers": [{"billed_charge": 1201.0, "npi": [1760020044]}, {"billed_charge": 762.0, "npi": [1760020044]}]}, {"allowed_amount": 140.76, "billing_code_modifier": [""], "providers": [{"billed_charge": 207.0, "npi": [1760020044]}]}, {"allowed_amount": 815.78, "billing_code_modifier": ["25"], "providers": [{"billed_charge": 1201.0, "npi": [1760020044]}]}, {"allowed_amount": 91.5467, "billing_code_modifier": [""], "providers": [{"billed_charge": 130.0, "npi": [1760020044]}]}, {"allowed_amount": 91.55, "billing_code_modifier": ["XU"], "providers": [{"billed_charge": 130.0, "npi": [1760020044]}]}, {"allowed_amount": 533.69, "billing_code_modifier": [""], "providers": [{"billed_charge": 762.0, "npi": [1760020044]}]}, {"allowed_amount": 300.19, "billing_code_modifier": ["25"], "providers": [{"billed_charge": 437.0, "npi": [1760020044]}]}, {"allowed_amount": 1164.31, "billing_code_modifier": [""], "providers": [{"billed_charge": 1720.0, "npi": [1760020044]}]}, {"allowed_amount": 91.545, "billing_code_modifier": [""], "providers": [{"billed_charge": 130.0, "npi": [1760020044]}]}]}]}, {"name": "ALCOHL  AND OR RX SRVC; METHADONE ADMIN  AND OR SERVICE", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "H0020", "description": "ALCOHL  AND OR RX SRVC; METHADONE ADMIN  AND OR SERVICE", "allowed_amounts": [{"tin": {"type": "ein", "value": "832996987"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 21.11, "billing_code_modifier": [""], "providers": [{"billed_charge": 49.0, "npi": [1093178766]}, {"billed_charge": 80.0, "npi": [1093178766]}, {"billed_charge": 60.0, "npi": [1093178766]}, {"billed_charge": 42.0, "npi": [1093178766]}, {"billed_charge": 57.0, "npi": [1093178766]}]}, {"allowed_amount": 21.11, "billing_code_modifier": ["HF"], "providers": [{"billed_charge": 80.0, "npi": [1093178766]}]}]}]}, {"name": "WEIGHT RECORDED", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "2001F", "description": "WEIGHT RECORDED", "allowed_amounts": [{"tin": {"type": "ein", "value": "237429653"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 0.01, "npi": [1831617265]}]}]}]}, {"name": "RVW ALL MEDS BY RXNG PRCTIONR OR CLIN RPH DOCD", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "1160F", "description": "RVW ALL MEDS BY RXNG PRCTIONR OR CLIN RPH DOCD", "allowed_amounts": [{"tin": {"type": "ein", "value": "237429653"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.0, "billing_code_modifier": [""], "providers": [{"billed_charge": 0.01, "npi": [1831617265]}]}]}]}, {"name": "Medical/Surgical Supplies and Devices - General", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0270", "description": "Med/Surg Supplies &Devices (also see 062x, extension of 027x", "allowed_amounts": [{"tin": {"type": "ein", "value": "822857014"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 0.35, "billing_code_modifier": [""], "providers": [{"billed_charge": 149.1, "npi": [1194229096]}]}]}]}, {"name": "Pharmacy - Extension of 25X - Drug Requiring Detailed Coding", "billing_code_type": "RC", "billing_code_type_version": "2022", "billing_code": "0636", "description": "Pharmacy - Extension of 25x", "allowed_amounts": [{"tin": {"type": "ein", "value": "751362671"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 19.69, "billing_code_modifier": [""], "providers": [{"billed_charge": 25.0, "npi": [1821025990]}]}, {"allowed_amount": 19.68, "billing_code_modifier": [""], "providers": [{"billed_charge": 25.0, "npi": [1821025990]}]}, {"allowed_amount": 21.26, "billing_code_modifier": [""], "providers": [{"billed_charge": 27.0, "npi": [1821025990]}]}]}]}, {"name": "DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL", "billing_code_type": "CPT", "billing_code_type_version": "2022", "billing_code": "90945", "description": "DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL", "allowed_amounts": [{"tin": {"type": "ein", "value": "953372911"}, "service_code": [""], "billing_class": "institutional", "payments": [{"allowed_amount": 141.73, "billing_code_modifier": [""], "providers": [{"billed_charge": 3778.0, "npi": [1568898971]}]}]}]}]}