{"reporting_entity_name": "Samaritan Health Plans","reporting_entity_type": "Samaritan Health Plans","last_updated_on": "2026-08-17","version": "2.0.0","out_of_network":[{"name":"Administration of 1 vaccine","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90471","description":"Administration of 1 vaccine","allowed_amounts":[{"tin":{"type":"ein","value":"421411630"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":57.98,"providers":[{"billed_charge":68.00,"npi":[1952717142]}]}]}]},{"name":"Alcohol and\/or drug services; subacute detoxification (residential addiction program inpatient)","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"H0010","description":"Alcohol and\/or drug services; subacute detoxification (residential addiction program inpatient)","allowed_amounts":[{"tin":{"type":"ein","value":"872765503"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":2639.70,"providers":[{"billed_charge":7500.00,"npi":[1841957057]}]}]}]},{"name":"Behavioral health; short term residential (non-hospital residential treatment program), without room and board, per diem","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"H0018","description":"Behavioral health; short term residential (non-hospital residential treatment program), without room and board, per diem","allowed_amounts":[{"tin":{"type":"ein","value":"872765503"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1753.54,"providers":[{"billed_charge":6900.00,"npi":[1841957057]},{"billed_charge":7900.00,"npi":[1841957057]}]}]}]},{"name":"Behavioral health; short term residential (non-hospital residential treatment program), without room and board, per diem","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"H0018","description":"Behavioral health; short term residential (non-hospital residential treatment program), without room and board, per diem","allowed_amounts":[{"tin":{"type":"ein","value":"992756563"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1753.54,"providers":[{"billed_charge":3825.00,"npi":[1518706324]}]}]}]},{"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":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":19.95,"providers":[{"billed_charge":35.00,"npi":[1881626943]}]}]}]},{"name":"Blood test, lipids (cholesterol and triglycerides)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80061","description":"Blood test, lipids (cholesterol and triglycerides)","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":46.00,"providers":[{"billed_charge":46.00,"npi":[1881626943]}]}]}]},{"name":"Calcifediol (25-Oh Vitamin D-3)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82306","description":"Calcifediol (25-Oh Vitamin D-3)","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":75.00,"providers":[{"billed_charge":75.00,"npi":[1881626943]}]}]}]},{"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":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":31.27,"providers":[{"billed_charge":80.00,"npi":[1881626943]}]}]}]},{"name":"Family Psychotherapy (Conjoint Psychotherapy) (W\/Patient Present)","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"90847GT","description":"Family Psychotherapy (Conjoint Psychotherapy) (W\/Patient Present)","allowed_amounts":[{"tin":{"type":"ein","value":"922173673"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":180.35,"providers":[{"billed_charge":205.00,"npi":[1851575211]}]}]}]},{"name":"Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90847","description":"Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes","allowed_amounts":[{"tin":{"type":"ein","value":"922173673"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":180.35,"providers":[{"billed_charge":205.00,"npi":[1851575211]}]}]}]},{"name":"Ground Mileage","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425RH","description":"Ground Mileage","allowed_amounts":[{"tin":{"type":"ein","value":"931916310"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":79.80,"providers":[{"billed_charge":114.00,"npi":[1649059148]}]}]}]},{"name":"Hemoglobin; glycosylated (A1C)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83036","description":"Hemoglobin; glycosylated (A1C)","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":31.28,"providers":[{"billed_charge":46.00,"npi":[1881626943]}]}]}]},{"name":"Hepatitis C Antibody","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86803","description":"Hepatitis C Antibody","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":52.84,"providers":[{"billed_charge":68.00,"npi":[1881626943]}]}]}]},{"name":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunoche","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87340","description":"Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunoche","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":31.27,"providers":[{"billed_charge":60.00,"npi":[1881626943]}]}]}]},{"name":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87491","description":"Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":86.27,"providers":[{"billed_charge":90.00,"npi":[1881626943]}]}]}]},{"name":"Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87591","description":"Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":86.27,"providers":[{"billed_charge":90.00,"npi":[1881626943]}]}]}]},{"name":"Office\/Op Visit, Est Pt, 2 Key Components: Detailed Hx; Detailed Exam; Med Decision Mod Complexity","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"99214GT","description":"Office\/Op Visit, Est Pt, 2 Key Components: Detailed Hx; Detailed Exam; Med Decision Mod Complexity","allowed_amounts":[{"tin":{"type":"ein","value":"203153475"},"service_code":["02"],"billing_class":"professional","payments":[{"allowed_amount":148.89,"providers":[{"billed_charge":175.00,"npi":[1205418779]}]}]}]},{"name":"Tet, Dipht Toxoids and Acellular Pertussis Vaccine (Tdap), for Individuals Seven Years or Older, for Intramuscular Use","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90715","description":"Tet, Dipht Toxoids and Acellular Pertussis Vaccine (Tdap), for Individuals Seven Years or Older, for Intramuscular Use","allowed_amounts":[{"tin":{"type":"ein","value":"421411630"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":47.03,"providers":[{"billed_charge":59.00,"npi":[1952717142]}]}]}]},{"name":"Thyroid Stimulating Hormone (Tsh)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84443","description":"Thyroid Stimulating Hormone (Tsh)","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.00,"providers":[{"billed_charge":45.00,"npi":[1881626943]}]}]}]},{"name":"Thyroxine; Free","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84439","description":"Thyroxine; Free","allowed_amounts":[{"tin":{"type":"ein","value":"954467199"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":32.35,"providers":[{"billed_charge":45.00,"npi":[1881626943]}]}]}]}]}
#5 - SP_OON_GET_DetailsInJSON_Transform upgrade was successfully