{"reporting_entity_name":"AultCare Corporation","reporting_entity_type":"Health Insurance Issuer","last_updated_on":"2026-07-03","version":"1.3.1","out_of_network":[{"name":"MEDICINE - CHIROPRACTIC MANIPU","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"98941","description":"CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS","allowed_amounts":[{"tin":{"type":"ein","value":"923082764"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":25.99,"billing_code_modifier":[],"providers":[{"billed_charge":75.00,"npi":[1134750433]}]}]},{"tin":{"type":"ein","value":"341821965"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":25.99,"billing_code_modifier":[],"providers":[{"billed_charge":68.60,"npi":[1598761371]}]}]},{"tin":{"type":"ein","value":"341566420"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":25.98,"billing_code_modifier":[],"providers":[{"billed_charge":60.00,"npi":[1649501156]}]}]}]},{"name":"E & M - OFFICE OR OTHER OUTPAT","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99214","description":"OFFICE OUTPATIENT VISIT 25 MINUTES","allowed_amounts":[{"tin":{"type":"ein","value":"203587332"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":115.39,"billing_code_modifier":["SA"],"providers":[{"billed_charge":257.00,"npi":[1619402070]}]},{"allowed_amount":106.75,"billing_code_modifier":["SA"],"providers":[{"billed_charge":257.00,"npi":[1700356730]}]},{"allowed_amount":107.87,"billing_code_modifier":["SA"],"providers":[{"billed_charge":257.00,"npi":[1861848509]}]}]},{"tin":{"type":"ein","value":"320506896"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":93.25,"billing_code_modifier":[],"providers":[{"billed_charge":368.03,"npi":[1538050422]}]}]}]},{"name":"E & M - OFFICE OR OTHER OUTPAT","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99202","description":"OFFICE OUTPATIENT NEW 20 MINUTES","allowed_amounts":[{"tin":{"type":"ein","value":"341289975"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":64.04,"billing_code_modifier":["25"],"providers":[{"billed_charge":126.08,"npi":[1679918288]}]},{"allowed_amount":66.61,"billing_code_modifier":["25"],"providers":[{"billed_charge":126.45,"npi":[1841301942]}]}]}]},{"name":"HCPCS - DENTAL","billing_code_type":"CDT","billing_code_type_version":"2026","billing_code":"D7240","description":"REMOVE IMPACTED TOOTH, COMPLETELY BONY","allowed_amounts":[{"tin":{"type":"ein","value":"341289975"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":541.00,"billing_code_modifier":[],"providers":[{"billed_charge":616.00,"npi":[1679918288]},{"billed_charge":617.03,"npi":[1841301942]}]}]}]},{"name":"HCPCS - DENTAL","billing_code_type":"CDT","billing_code_type_version":"2026","billing_code":"D9222","description":"DEEP SEDATION/GENERAL ANESTHESIA – FIRST 15 MINUTES","allowed_amounts":[{"tin":{"type":"ein","value":"341289975"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":263.15,"billing_code_modifier":[],"providers":[{"billed_charge":263.15,"npi":[1679918288]}]},{"allowed_amount":263.86,"billing_code_modifier":[],"providers":[{"billed_charge":263.86,"npi":[1841301942]}]}]}]},{"name":"HCPCS - DENTAL","billing_code_type":"CDT","billing_code_type_version":"2026","billing_code":"D9223","description":"DEEP SEDATION/GENERAL ANESTHESIA – EACH SUBSEQUENT 15 MINUTE","allowed_amounts":[{"tin":{"type":"ein","value":"341289975"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":264.28,"billing_code_modifier":[],"providers":[{"billed_charge":268.30,"npi":[1679918288]}]},{"allowed_amount":265.16,"billing_code_modifier":[],"providers":[{"billed_charge":269.10,"npi":[1841301942]}]}]}]},{"name":"HCPCS - DENTAL","billing_code_type":"CDT","billing_code_type_version":"2026","billing_code":"D9612","description":"THERAPEUTIC PARENTERAL DRUGS, 2 OR MORE ADMIN","allowed_amounts":[{"tin":{"type":"ein","value":"341289975"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":60.80,"billing_code_modifier":[],"providers":[{"billed_charge":172.30,"npi":[1679918288]},{"billed_charge":172.79,"npi":[1841301942]}]}]}]},{"name":"SURGERY - CARDIOVASCULAR SYSTE","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"COLLECTION VENOUS BLOOD VENIPUNCTURE","allowed_amounts":[{"tin":{"type":"ein","value":"311480941"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1.24,"billing_code_modifier":[],"providers":[{"billed_charge":30.40,"npi":[1598868655]}]}]},{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":7.89,"billing_code_modifier":[],"providers":[{"billed_charge":25.63,"npi":[1932184322]}]}]},{"tin":{"type":"ein","value":"341893439"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":37.41,"billing_code_modifier":[],"providers":[{"billed_charge":62.26,"npi":[1366433195]}]}]}]},{"name":"E & M - OFFICE OR OTHER OUTPAT","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99204","description":"OFFICE OUTPATIENT NEW 45 MINUTES","allowed_amounts":[{"tin":{"type":"ein","value":"203587332"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":139.89,"billing_code_modifier":["SA"],"providers":[{"billed_charge":251.25,"npi":[1700356730]}]},{"allowed_amount":140.22,"billing_code_modifier":["SA"],"providers":[{"billed_charge":251.25,"npi":[1861848509]}]}]}]},{"name":"E & M - OFFICE OR OTHER OUTPAT","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99213","description":"OFFICE OUTPATIENT VISIT 15 MINUTES","allowed_amounts":[{"tin":{"type":"ein","value":"203587332"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":76.14,"billing_code_modifier":["SA"],"providers":[{"billed_charge":182.00,"npi":[1861848509]}]}]}]},{"name":"HCPCS - TEMP NATIONAL CODES","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"S9124","description":"NURSING CARE, IN THE HOME; BY LPN, PER HOUR","allowed_amounts":[{"tin":{"type":"ein","value":"521590951"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":60.00,"billing_code_modifier":[],"providers":[{"billed_charge":60.00,"npi":[1669437919]}]}]}]},{"name":"MEDICINE - PSYCHIATRY","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90837","description":"PSYCHOTHERAPY PATIENT &/ FAMILY 60 MINUTES","allowed_amounts":[{"tin":{"type":"ein","value":"273022435"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":102.54,"billing_code_modifier":[],"providers":[{"billed_charge":180.00,"npi":[1760504336]}]}]}]},{"name":"PATH & LAB - SURGICAL PATHOLOG","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"88305","description":"LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM","allowed_amounts":[{"tin":{"type":"ein","value":"310895497"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":32.47,"billing_code_modifier":["26"],"providers":[{"billed_charge":275.00,"npi":[1811167133]}]}]}]},{"name":"HCPCS - PROC/PROF SERVICES (TE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0480","description":"DRUG TEST(S) DEF 1-7 CLASSES","allowed_amounts":[{"tin":{"type":"ein","value":"453350742"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":62.14,"billing_code_modifier":[],"providers":[{"billed_charge":1100.00,"npi":[1982975421]}]}]}]},{"name":"HCPCS - PROC/PROF SERVICES (TE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0481","description":"DRUG TEST(S) DEF 8-14 CLASSES","allowed_amounts":[{"tin":{"type":"ein","value":"453350742"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":79.25,"billing_code_modifier":[],"providers":[{"billed_charge":1500.00,"npi":[1982975421]}]}]}]},{"name":"HCPCS - PROC/PROF SERVICES (TE","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0463","description":"HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSMNT MNGT","allowed_amounts":[{"tin":{"type":"ein","value":"421562638"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":169.78,"billing_code_modifier":[],"providers":[{"billed_charge":381.30,"npi":[1740398890]}]}]}]}]}