{"reporting_entity_name": "Samaritan Health Plans","reporting_entity_type": "Samaritan Health Plans","last_updated_on": "2026-04-16","version": "1.0.0","out_of_network":[{"name":"Basic Metabolic Panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80048","description":"Basic Metabolic Panel","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":290.94,"providers":[{"billed_charge":388.00,"npi":[1174582050]}]}]}]},{"name":"Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85027","description":"Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":72.73,"providers":[{"billed_charge":97.00,"npi":[1174582050]}]}]}]},{"name":"Bone &\/Or Joint Imaging; Whole Body","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"78306","description":"Bone &\/Or Joint Imaging; Whole Body","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1333.50,"providers":[{"billed_charge":1778.00,"npi":[1174582050]}]}]}]},{"name":"Computed Tomography, Abdomen And Pelvis; With Contrast Material(S)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"74177","description":"Computed Tomography, Abdomen And Pelvis; With Contrast Material(S)","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":4936.82,"providers":[{"billed_charge":6586.00,"npi":[1174582050]}]}]}]},{"name":"Computed tomography, thorax, diagnostic; with contrast material(s)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"71260","description":"Computed tomography, thorax, diagnostic; with contrast material(s)","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":2672.30,"providers":[{"billed_charge":3565.00,"npi":[1174582050]}]}]}]},{"name":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT,","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80307","description":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT,","allowed_amounts":[{"tin":{"type":"ein","value":"463908799"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":49.71,"providers":[{"billed_charge":120.00,"npi":[1093136418]}]}]}]},{"name":"Drug test, definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily steroisomers)","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0482","description":"Drug test, definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily steroisomers)","allowed_amounts":[{"tin":{"type":"ein","value":"463908799"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":158.99,"providers":[{"billed_charge":220.00,"npi":[1093136418]}]}]}]},{"name":"Drugs Unclassified Injection","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J3490","description":"Drugs Unclassified Injection","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":7.80,"providers":[{"billed_charge":10.40,"npi":[1174582050]}]}]}]},{"name":"Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99213","description":"Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more","allowed_amounts":[{"tin":{"type":"ein","value":"205824138"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":61.27,"providers":[{"billed_charge":330.00,"npi":[1457037624,1528833449,1972572147]}]}]}]},{"name":"Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99213","description":"Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":205.39,"providers":[{"billed_charge":274.00,"npi":[1174582050]}]}]}]},{"name":"Ground Mileage","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425RH","description":"Ground Mileage","allowed_amounts":[{"tin":{"type":"ein","value":"930956370"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":305.03,"providers":[{"billed_charge":435.75,"npi":[1730280447]}]}]}]},{"name":"Immunohistochemistry (W\/Tissue Immunoperoxidase), Each Antibody","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"88342","description":"Immunohistochemistry (W\/Tissue Immunoperoxidase), Each Antibody","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":265.00,"npi":[1174582050]}]}]}]},{"name":"Low osmolar contrast material, 300-399 mg\/ml iodine concentration, per ml","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"Q9967","description":"Low osmolar contrast material, 300-399 mg\/ml iodine concentration, per ml","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":112.44,"providers":[{"billed_charge":150.00,"npi":[1174582050]}]}]}]},{"name":"Medical\/Surgical Supplies and Devices - Sterile Supply","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0272","description":"Medical\/Surgical Supplies and Devices - Sterile Supply","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":77.33,"providers":[{"billed_charge":103.13,"npi":[1174582050]}]}]}]},{"name":"Microdissection (ie, Sample Preparation of Microscopically Identified Target); Manual","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"88381","description":"Microdissection (ie, Sample Preparation of Microscopically Identified Target); Manual","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":246.75,"providers":[{"billed_charge":329.00,"npi":[1174582050]}]}]}]},{"name":"Prothrombin Time","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85610","description":"Prothrombin Time","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":72.73,"providers":[{"billed_charge":97.00,"npi":[1174582050]}]}]}]},{"name":"Recovery Room","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0710","description":"Recovery Room","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":623.12,"providers":[{"billed_charge":831.00,"npi":[1174582050]}]}]}]},{"name":"Technetium Tc 99m Medronate","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A9503","description":"Technetium Tc 99m Medronate","allowed_amounts":[{"tin":{"type":"ein","value":"746001118"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":54.75,"providers":[{"billed_charge":73.00,"npi":[1174582050]}]}]}]},{"name":"Urinalysis, Dip Stick\/Tablet Reagent; Automated, W\/O Microscopy","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"81003QW","description":"Urinalysis, Dip Stick\/Tablet Reagent; Automated, W\/O Microscopy","allowed_amounts":[{"tin":{"type":"ein","value":"205824138"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":3.67,"providers":[{"billed_charge":20.00,"npi":[1528833449,1972572147]}]}]}]}]}