{ "reporting_entity_name" : "HealthPlanName", "reporting_entity_type" : "HealthPlanType", "last_updated_on" : "2024-12-02", "version" : "1.0.0", "out_of_network" : [ { "name" : "SARS-COV-2 COVID19 W/OPTIC", "billing_code_type" : "CPT", "billing_code_type_version" : "2023", "billing_code" : "87811", "description" : "Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])", "allowed_amounts" : [ { "tin" : { "type" : "ein", "value" : "87-2642408" }, "service_code" : [ "81" ], "billing_class" : "professional", "payments" : [ { "allowed_amount" : 41.38, "billing_code_modifier" : [ "QW" ], "providers" : [ { "billed_charge" : 325.00, "npi" : [ 1154089241 ] } ] } ] } ] }, { "name" : "OFFICE/OUTPATIENT VISIT EST", "billing_code_type" : "CPT", "billing_code_type_version" : "2023", "billing_code" : "99214", "description" : "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.", "allowed_amounts" : [ { "tin" : { "type" : "ein", "value" : "75-2510007" }, "service_code" : [ "20" ], "billing_class" : "professional", "payments" : [ { "allowed_amount" : 201.00, "providers" : [ { "billed_charge" : 334.00, "npi" : [ 1770048704 ] } ] }, { "allowed_amount" : 155.00, "providers" : [ { "billed_charge" : 334.00, "npi" : [ 1770048704 ] } ] } ] } ] }, { "name" : "OFFICE/OUTPATIENT VISIT NEW", "billing_code_type" : "CPT", "billing_code_type_version" : "2023", "billing_code" : "99204", "description" : "Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.", "allowed_amounts" : [ { "tin" : { "type" : "ein", "value" : "75-2510007" }, "service_code" : [ "20" ], "billing_class" : "professional", "payments" : [ { "allowed_amount" : 201.00, "providers" : [ { "billed_charge" : 503.00, "npi" : [ 1770048704 ] } ] }, { "allowed_amount" : 155.00, "providers" : [ { "billed_charge" : 503.00, "npi" : [ 1770048704 ] } ] } ] } ] } ] }