{"reporting_entity_name":"Allegiance Benefit Plan Mgmt","reporting_entity_type":"third party","last_updated_on":"2026-06-22","version":"2.0.0","out_of_network":[{"name":"Rx mbr clms - with stop loss","billing_code_type":"HCPCS","billing_code":"RXCPY","billing_code_type_version":"2026","description":"Rx mbr clms - with stop loss","allowed_amounts":[{"tin":{"type":"npi","value":"752676894"},"service_code":["*P"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":1.99,"billing_code_modifier":["  "],"providers":[{"billed_charge":1.99,"npi":[]}]},{"allowed_amount":2.57,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.57,"npi":[]}]},{"allowed_amount":2.58,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.58,"npi":[]}]},{"allowed_amount":2.63,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.63,"npi":[]}]},{"allowed_amount":2.67,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.67,"npi":[]}]},{"allowed_amount":2.70,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.70,"npi":[]}]},{"allowed_amount":2.80,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.80,"npi":[]}]},{"allowed_amount":2.90,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.90,"npi":[]}]},{"allowed_amount":2.92,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.92,"npi":[]}]},{"allowed_amount":2.95,"billing_code_modifier":["  "],"providers":[{"billed_charge":2.95,"npi":[]}]},{"allowed_amount":3.09,"billing_code_modifier":["  "],"providers":[{"billed_charge":3.09,"npi":[]}]},{"allowed_amount":3.27,"billing_code_modifier":["  "],"providers":[{"billed_charge":3.27,"npi":[]}]},{"allowed_amount":4.15,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.15,"npi":[]}]},{"allowed_amount":4.25,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.25,"npi":[]}]},{"allowed_amount":4.28,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.28,"npi":[]}]},{"allowed_amount":4.29,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.29,"npi":[]}]},{"allowed_amount":4.42,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.42,"npi":[]}]},{"allowed_amount":4.57,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.57,"npi":[]}]},{"allowed_amount":4.62,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.62,"npi":[]}]},{"allowed_amount":4.72,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.72,"npi":[]}]},{"allowed_amount":4.74,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.74,"npi":[]}]},{"allowed_amount":4.75,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.75,"npi":[]}]},{"allowed_amount":4.81,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.81,"npi":[]}]},{"allowed_amount":4.94,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.94,"npi":[]}]},{"allowed_amount":4.96,"billing_code_modifier":["  "],"providers":[{"billed_charge":4.96,"npi":[]}]},{"allowed_amount":5.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":5.00,"npi":[]}]},{"allowed_amount":5.01,"billing_code_modifier":["  "],"providers":[{"billed_charge":5.01,"npi":[]}]},{"allowed_amount":5.07,"billing_code_modifier":["  "],"providers":[{"billed_charge":5.07,"npi":[]}]},{"allowed_amount":5.19,"billing_code_modifier":["  "],"providers":[{"billed_charge":5.19,"npi":[]}]},{"allowed_amount":5.63,"billing_code_modifier":["  "],"providers":[{"billed_charge":5.63,"npi":[]}]},{"allowed_amount":5.77,"billing_code_modifier":["  "],"providers":[{"billed_charge":5.77,"npi":[]}]},{"allowed_amount":5.90,"billing_code_modifier":["  "],"providers":[{"billed_charge":5.90,"npi":[]}]},{"allowed_amount":6.08,"billing_code_modifier":["  "],"providers":[{"billed_charge":6.08,"npi":[]}]},{"allowed_amount":6.10,"billing_code_modifier":["  "],"providers":[{"billed_charge":6.10,"npi":[]}]},{"allowed_amount":6.47,"billing_code_modifier":["  "],"providers":[{"billed_charge":6.47,"npi":[]}]},{"allowed_amount":6.69,"billing_code_modifier":["  "],"providers":[{"billed_charge":6.69,"npi":[]}]},{"allowed_amount":6.89,"billing_code_modifier":["  "],"providers":[{"billed_charge":6.89,"npi":[]}]},{"allowed_amount":7.70,"billing_code_modifier":["  "],"providers":[{"billed_charge":7.70,"npi":[]}]},{"allowed_amount":8.23,"billing_code_modifier":["  "],"providers":[{"billed_charge":8.23,"npi":[]}]},{"allowed_amount":8.54,"billing_code_modifier":["  "],"providers":[{"billed_charge":8.54,"npi":[]}]},{"allowed_amount":9.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":9.00,"npi":[]}]},{"allowed_amount":9.06,"billing_code_modifier":["  "],"providers":[{"billed_charge":9.06,"npi":[]}]},{"allowed_amount":9.20,"billing_code_modifier":["  "],"providers":[{"billed_charge":9.20,"npi":[]}]},{"allowed_amount":9.25,"billing_code_modifier":["  "],"providers":[{"billed_charge":9.25,"npi":[]}]},{"allowed_amount":9.82,"billing_code_modifier":["  "],"providers":[{"billed_charge":9.82,"npi":[]}]},{"allowed_amount":10.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":10.00,"npi":[]}]},{"allowed_amount":10.10,"billing_code_modifier":["  "],"providers":[{"billed_charge":10.10,"npi":[]}]},{"allowed_amount":10.39,"billing_code_modifier":["  "],"providers":[{"billed_charge":10.39,"npi":[]}]},{"allowed_amount":10.91,"billing_code_modifier":["  "],"providers":[{"billed_charge":10.91,"npi":[]}]},{"allowed_amount":10.94,"billing_code_modifier":["  "],"providers":[{"billed_charge":10.94,"npi":[]}]},{"allowed_amount":11.14,"billing_code_modifier":["  "],"providers":[{"billed_charge":11.14,"npi":[]}]},{"allowed_amount":12.50,"billing_code_modifier":["  "],"providers":[{"billed_charge":12.50,"npi":[]}]},{"allowed_amount":13.16,"billing_code_modifier":["  "],"providers":[{"billed_charge":13.16,"npi":[]}]},{"allowed_amount":14.18,"billing_code_modifier":["  "],"providers":[{"billed_charge":14.18,"npi":[]}]},{"allowed_amount":14.23,"billing_code_modifier":["  "],"providers":[{"billed_charge":14.23,"npi":[]}]},{"allowed_amount":14.63,"billing_code_modifier":["  "],"providers":[{"billed_charge":14.63,"npi":[]}]},{"allowed_amount":15.19,"billing_code_modifier":["  "],"providers":[{"billed_charge":15.19,"npi":[]}]},{"allowed_amount":16.86,"billing_code_modifier":["  "],"providers":[{"billed_charge":16.86,"npi":[]}]},{"allowed_amount":17.21,"billing_code_modifier":["  "],"providers":[{"billed_charge":17.21,"npi":[]}]},{"allowed_amount":17.50,"billing_code_modifier":["  "],"providers":[{"billed_charge":17.50,"npi":[]}]},{"allowed_amount":19.24,"billing_code_modifier":["  "],"providers":[{"billed_charge":19.24,"npi":[]}]},{"allowed_amount":22.28,"billing_code_modifier":["  "],"providers":[{"billed_charge":22.28,"npi":[]}]},{"allowed_amount":23.96,"billing_code_modifier":["  "],"providers":[{"billed_charge":23.96,"npi":[]}]},{"allowed_amount":24.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":24.00,"npi":[]}]},{"allowed_amount":24.24,"billing_code_modifier":["  "],"providers":[{"billed_charge":24.24,"npi":[]}]},{"allowed_amount":24.48,"billing_code_modifier":["  "],"providers":[{"billed_charge":24.48,"npi":[]}]},{"allowed_amount":25.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":25.00,"npi":[]}]},{"allowed_amount":35.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":35.00,"npi":[]}]},{"allowed_amount":43.50,"billing_code_modifier":["  "],"providers":[{"billed_charge":43.50,"npi":[]}]},{"allowed_amount":60.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":60.00,"npi":[]}]},{"allowed_amount":87.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":87.00,"npi":[]}]},{"allowed_amount":125.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":125.00,"npi":[]}]}]}]}]}