{
  "reporting_entity_name" : "HealthPlan",
  "reporting_entity_type" : "HealthPlan",
  "last_updated_on" : "2023-11-01",
  "version" : "1.0.0",
  "out_of_network" : [ {
    "name" : "SERVICES PROVIDED IN AN URGENT CARE CENTER",
    "billing_code_type" : "HCPCS",
    "billing_code_type_version" : "2022",
    "billing_code" : "S9088",
    "description" : "Services provided in an urgent care center (list in addition to code for service)",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "81-2117336"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 17.50,
        "providers" : [ {
          "billed_charge" : 35.00,
          "npi" : [ 1003928060 ]
        } ]
      } ]
    } ]
  } ]
}