{"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":"Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85025","description":"Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count","allowed_amounts":[{"tin":{"type":"ein","value":"542183222"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":37.20,"npi":[1992865828]}]}]}]},{"name":"C-Reactive Protein","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86140","description":"C-Reactive Protein","allowed_amounts":[{"tin":{"type":"ein","value":"542183222"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":25.20,"npi":[1992865828]}]}]}]},{"name":"Comprehensive Metabolic Panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80053","description":"Comprehensive Metabolic Panel","allowed_amounts":[{"tin":{"type":"ein","value":"542183222"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":50.40,"npi":[1992865828]}]}]}]},{"name":"Lipase","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83690","description":"Lipase","allowed_amounts":[{"tin":{"type":"ein","value":"542183222"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":33.60,"npi":[1992865828]}]}]}]},{"name":"Medication list documented in medical record (COA)2","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"1159F","description":"Medication list documented in medical record (COA)2","allowed_amounts":[{"tin":{"type":"ein","value":"542183222"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1992865828]}]}]}]},{"name":"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 le","billing_code_type":"CPT","billing_code_type_version":"2026","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 le","allowed_amounts":[{"tin":{"type":"ein","value":"542183222"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":266.87,"providers":[{"billed_charge":266.87,"npi":[1992865828]}]}]}]}]}
