{"reporting_entity_name":"Allegiance Benefit Plan Mgmt","reporting_entity_type":"third party","last_updated_on":"2026-07-28","version":"2.0.0","out_of_network":[{"name":"Comprehen Metabolic Panel","billing_code_type":"CPT","billing_code":"80053","billing_code_type_version":"2026","description":"Comprehen Metabolic Panel","allowed_amounts":[{"tin":{"type":"npi","value":"370955439"},"service_code":["21"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":4.49,"billing_code_modifier":["26"],"providers":[{"billed_charge":20.97,"npi":[1003067661]}]}]},{"tin":{"type":"npi","value":"370955439"},"service_code":["22"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":4.49,"billing_code_modifier":["  "],"providers":[{"billed_charge":20.97,"npi":[1003067661]}]},{"allowed_amount":4.49,"billing_code_modifier":["26"],"providers":[{"billed_charge":20.97,"npi":[1003067661]}]}]},{"tin":{"type":"npi","value":"370955439"},"service_code":["23"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":4.49,"billing_code_modifier":["  "],"providers":[{"billed_charge":20.97,"npi":[1003067661]}]},{"allowed_amount":4.49,"billing_code_modifier":["26"],"providers":[{"billed_charge":20.97,"npi":[1003067661]}]}]}]},{"name":"Bld cnt, compl CBC w\/auto diff","billing_code_type":"CPT","billing_code":"85025","billing_code_type_version":"2026","description":"Bld cnt, compl CBC w\/auto diff","allowed_amounts":[{"tin":{"type":"npi","value":"370955439"},"service_code":["21"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":4.49,"billing_code_modifier":["26"],"providers":[{"billed_charge":11.60,"npi":[1003067661]}]}]},{"tin":{"type":"npi","value":"370955439"},"service_code":["22"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":4.49,"billing_code_modifier":["  "],"providers":[{"billed_charge":11.60,"npi":[1003067661]}]},{"allowed_amount":4.49,"billing_code_modifier":["26"],"providers":[{"billed_charge":11.60,"npi":[1003067661]}]}]},{"tin":{"type":"npi","value":"370955439"},"service_code":["23"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":4.49,"billing_code_modifier":["  "],"providers":[{"billed_charge":11.60,"npi":[1003067661]}]},{"allowed_amount":4.49,"billing_code_modifier":["26"],"providers":[{"billed_charge":11.60,"npi":[1003067661]}]}]}]},{"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":"371161304"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":24.79,"billing_code_modifier":["  "],"providers":[{"billed_charge":50.00,"npi":[1639234404]},{"billed_charge":50.00,"npi":[1841561842]},{"billed_charge":55.00,"npi":[1639234404]},{"billed_charge":55.00,"npi":[1841561842]}]}]}]},{"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":"050613324"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":35.67,"billing_code_modifier":["  "],"providers":[{"billed_charge":60.00,"npi":[1174569834]}]}]},{"tin":{"type":"npi","value":"260440649"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":35.67,"billing_code_modifier":["  "],"providers":[{"billed_charge":60.00,"npi":[1588674204]}]},{"allowed_amount":35.67,"billing_code_modifier":["AT"],"providers":[{"billed_charge":60.00,"npi":[1588674204]}]}]},{"tin":{"type":"npi","value":"371351125"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":35.67,"billing_code_modifier":["  "],"providers":[{"billed_charge":70.00,"npi":[]}]}]},{"tin":{"type":"npi","value":"453943936"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":35.67,"billing_code_modifier":["  "],"providers":[{"billed_charge":67.00,"npi":[1164758314]}]}]},{"tin":{"type":"npi","value":"474625153"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":35.67,"billing_code_modifier":["  "],"providers":[{"billed_charge":67.00,"npi":[1154482958]}]}]},{"tin":{"type":"npi","value":"814968602"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":35.67,"billing_code_modifier":["  "],"providers":[{"billed_charge":64.00,"npi":[1114260452]}]}]}]},{"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":"050613324"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":24.92,"billing_code_modifier":["  "],"providers":[{"billed_charge":60.00,"npi":[1174569834]}]}]}]}]}