{"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":"PSYTX W PT 45 MINUTES","billing_code_type":"CPT","billing_code":"90834","billing_code_type_version":"2026","description":"PSYTX W PT 45 MINUTES","allowed_amounts":[{"tin":{"type":"npi","value":"077501602"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":80.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":80.00,"npi":[]}]}]},{"tin":{"type":"npi","value":"411759724"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":180.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":180.00,"npi":[1326184086]}]}]},{"tin":{"type":"npi","value":"833649642"},"service_code":["10"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":185.00,"billing_code_modifier":["95"],"providers":[{"billed_charge":185.00,"npi":[1942010319]}]}]}]},{"name":"PSYTX W PT 60 MINUTES","billing_code_type":"CPT","billing_code":"90837","billing_code_type_version":"2026","description":"PSYTX W PT 60 MINUTES","allowed_amounts":[{"tin":{"type":"npi","value":"208225522"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":70.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":70.00,"npi":[]},{"billed_charge":70.00,"npi":[1255843488]}]}]},{"tin":{"type":"npi","value":"497047317"},"service_code":["02"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":150.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":150.00,"npi":[1710264494]}]}]},{"tin":{"type":"npi","value":"497047317"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":150.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":150.00,"npi":[1710264494]}]}]},{"tin":{"type":"npi","value":"810883118"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":120.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":120.00,"npi":[1942879416]}]}]}]},{"name":"PSYTX W PT W E\/M 60 MIN","billing_code_type":"CPT","billing_code":"90838","billing_code_type_version":"2026","description":"PSYTX W PT W E\/M 60 MIN","allowed_amounts":[{"tin":{"type":"npi","value":"070309868"},"service_code":["02"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":468.86,"billing_code_modifier":["  "],"providers":[{"billed_charge":550.00,"npi":[1235325721]}]},{"allowed_amount":468.86,"billing_code_modifier":["95"],"providers":[{"billed_charge":550.00,"npi":[1235325721]}]}]}]},{"name":"Psychotherapy, group (no multi","billing_code_type":"CPT","billing_code":"90853","billing_code_type_version":"2026","description":"Psychotherapy, group (no multi","allowed_amounts":[{"tin":{"type":"npi","value":"841233862"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":100.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":100.00,"npi":[1780849760]}]}]}]},{"name":"Speech\/hearing therapy, indivi","billing_code_type":"CPT","billing_code":"92507","billing_code_type_version":"2026","description":"Speech\/hearing therapy, indivi","allowed_amounts":[{"tin":{"type":"npi","value":"831887984"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":240.00,"billing_code_modifier":["96"],"providers":[{"billed_charge":240.00,"npi":[1730673153]}]}]}]},{"name":"Apply modality,1+area,traction","billing_code_type":"CPT","billing_code":"97012","billing_code_type_version":"2026","description":"Apply modality,1+area,traction","allowed_amounts":[{"tin":{"type":"npi","value":"273427870"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":65.00,"billing_code_modifier":["GP"],"providers":[{"billed_charge":65.00,"npi":[1184766339]}]}]},{"tin":{"type":"npi","value":"842252537"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":45.00,"billing_code_modifier":["59"],"providers":[{"billed_charge":45.00,"npi":[1508488867]}]}]}]},{"name":"Tx proc,1+area,Tx exer, ea 15 ","billing_code_type":"CPT","billing_code":"97110","billing_code_type_version":"2026","description":"Tx proc,1+area,Tx exer, ea 15 ","allowed_amounts":[{"tin":{"type":"npi","value":"273427870"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":75.00,"billing_code_modifier":["GP"],"providers":[{"billed_charge":75.00,"npi":[1184766339]}]}]},{"tin":{"type":"npi","value":"822181006"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":450.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":450.00,"npi":[1881053866]}]}]},{"tin":{"type":"npi","value":"842252537"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":260.00,"billing_code_modifier":["59"],"providers":[{"billed_charge":260.00,"npi":[1508488867]}]}]}]},{"name":"Tx proc,1+area,neuro reedu,ea ","billing_code_type":"CPT","billing_code":"97112","billing_code_type_version":"2026","description":"Tx proc,1+area,neuro reedu,ea ","allowed_amounts":[{"tin":{"type":"npi","value":"357720637"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":40.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":40.00,"npi":[1518040583]}]},{"allowed_amount":40.00,"billing_code_modifier":["GP"],"providers":[{"billed_charge":40.00,"npi":[1518040583]}]}]},{"tin":{"type":"npi","value":"822181006"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":450.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":450.00,"npi":[1881053866]}]}]}]},{"name":"MANUAL THERAPY 1\/> REGIONS","billing_code_type":"CPT","billing_code":"97140","billing_code_type_version":"2026","description":"MANUAL THERAPY 1\/> REGIONS","allowed_amounts":[{"tin":{"type":"npi","value":"260059108"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":20.00,"billing_code_modifier":["59"],"providers":[{"billed_charge":20.00,"npi":[1285729608]}]}]},{"tin":{"type":"npi","value":"357720637"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":40.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":40.00,"npi":[1518040583]}]},{"allowed_amount":40.00,"billing_code_modifier":["59"],"providers":[{"billed_charge":40.00,"npi":[1518040583]}]},{"allowed_amount":40.00,"billing_code_modifier":["GP"],"providers":[{"billed_charge":40.00,"npi":[1518040583]}]}]},{"tin":{"type":"npi","value":"822181006"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":150.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":150.00,"npi":[1881053866]}]}]}]},{"name":"ADAPTIVE BEHAVIOR TX BY TECH","billing_code_type":"CPT","billing_code":"97153","billing_code_type_version":"2026","description":"ADAPTIVE BEHAVIOR TX BY TECH","allowed_amounts":[{"tin":{"type":"npi","value":"881340222"},"service_code":["12"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":240.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":240.00,"npi":[1982426201]}]}]}]},{"name":"Tx activities, direct pt, ea 1","billing_code_type":"CPT","billing_code":"97530","billing_code_type_version":"2026","description":"Tx activities, direct pt, ea 1","allowed_amounts":[{"tin":{"type":"npi","value":"262534401"},"service_code":["12"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":180.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":200.00,"npi":[1730504689]}]}]},{"tin":{"type":"npi","value":"482907620"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":380.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":380.00,"npi":[1801961529]}]}]},{"tin":{"type":"npi","value":"482907620"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":380.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":380.00,"npi":[1801961529]}]}]}]},{"name":"CMT, spinal, 1-2 regions","billing_code_type":"CPT","billing_code":"98940","billing_code_type_version":"2026","description":"CMT, spinal, 1-2 regions","allowed_amounts":[{"tin":{"type":"npi","value":"260059108"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":50.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":50.00,"npi":[1285729608]}]}]}]},{"name":"CMT, spinal, 3-4 regions","billing_code_type":"CPT","billing_code":"98941","billing_code_type_version":"2026","description":"CMT, spinal, 3-4 regions","allowed_amounts":[{"tin":{"type":"npi","value":"273427870"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":90.00,"billing_code_modifier":["AT"],"providers":[{"billed_charge":90.00,"npi":[1184766339]}]}]},{"tin":{"type":"npi","value":"815235759"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":55.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":55.00,"npi":[1811205602]}]},{"allowed_amount":55.00,"billing_code_modifier":["AT"],"providers":[{"billed_charge":55.00,"npi":[1811205602]}]}]},{"tin":{"type":"npi","value":"821383594"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":60.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":60.00,"npi":[1932635786]}]}]},{"tin":{"type":"npi","value":"842252537"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":75.00,"billing_code_modifier":["AT"],"providers":[{"billed_charge":75.00,"npi":[1508488867]}]}]}]},{"name":"CMT, extraspinal, one or more ","billing_code_type":"CPT","billing_code":"98943","billing_code_type_version":"2026","description":"CMT, extraspinal, one or more ","allowed_amounts":[{"tin":{"type":"npi","value":"842252537"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":45.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":45.00,"npi":[1508488867]}]}]}]},{"name":"Office\/Outpatient Visit Est","billing_code_type":"CPT","billing_code":"99212","billing_code_type_version":"2026","description":"Office\/Outpatient Visit Est","allowed_amounts":[{"tin":{"type":"npi","value":"357720637"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":85.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":85.00,"npi":[1518040583]}]},{"allowed_amount":85.00,"billing_code_modifier":["25"],"providers":[{"billed_charge":85.00,"npi":[1518040583]}]}]}]},{"name":"Office\/Outpatient Visit Est","billing_code_type":"CPT","billing_code":"99214","billing_code_type_version":"2026","description":"Office\/Outpatient Visit Est","allowed_amounts":[{"tin":{"type":"npi","value":"070309868"},"service_code":["02"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":528.51,"billing_code_modifier":["95"],"providers":[{"billed_charge":550.00,"npi":[1235325721]}]}]}]},{"name":"Emergency dept visit, detailed","billing_code_type":"CPT","billing_code":"99284","billing_code_type_version":"2026","description":"Emergency dept visit, detailed","allowed_amounts":[{"tin":{"type":"npi","value":"873666354"},"service_code":["23"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":214.66,"billing_code_modifier":["  "],"providers":[{"billed_charge":1090.00,"npi":[1083697122]},{"billed_charge":1090.00,"npi":[1386675809]},{"billed_charge":1090.00,"npi":[1497701510]},{"billed_charge":1090.00,"npi":[1588255772]},{"billed_charge":1090.00,"npi":[1700869112]},{"billed_charge":1090.00,"npi":[1770163099]},{"billed_charge":1090.00,"npi":[1770714776]},{"billed_charge":1090.00,"npi":[1801450101]},{"billed_charge":1090.00,"npi":[1841654712]},{"billed_charge":1090.00,"npi":[1902120819]},{"billed_charge":1090.00,"npi":[1912414327]}]}]}]}]}
