price-transparency-guide/examples/allowed-amounts/allowed-amounts-single-plan-sample.json at 2de9e27870123d8852fa3bcc7cac83cd7d4914f1 · clovis517/price-transparency-guide · GitHub

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{
  "reporting_entity_name": "cms",
  "reporting_entity_type": "cms",
  "plan_name": "medicare",
  "plan_id_type": "hios",
  "plan_id": "1111111111",
  "plan_market_type": "individual",
  "last_updated_on": "2020-08-27",
  "version": "2.0.0",
  "out_of_network": [
    {
      "name": "Established Patient Office or Other Outpatient Services",
      "billing_code_type": "CPT",
      "billing_code_type_version": "2020",
      "billing_code": "99214",
      "description": "office or other outpatient visits for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination and medical decision making of moderate complexity",
      "allowed_amounts": [
        {
          "tin": {
            "type": "ein",
            "value": "1234567890"
          },
          "service_code": ["01", "02", "03"],
          "billing_class": "professional",
          "setting": "outpatient",
          "payments": [
            {
              "allowed_amount": 25.0,
              "billing_code_modifier": ["25"],
              "providers": [
                {
                  "billed_charge": 50.0,
                  "npi": [1234567891, 1234567892, 1234567893]
                },
                {
                  "billed_charge": 60.0,
                  "npi": [1111111111]
                },
                {
                  "billed_charge": 70.0,
                  "npi": [2222222222, 3333333333, 4444444444, 5555555555]
                }
              ]
            }
          ]
        }
      ]
    }
  ]
}