{"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":"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":"273080192"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":42.38,"billing_code_modifier":["GP"],"providers":[{"billed_charge":58.00,"npi":[1518330927]},{"billed_charge":58.00,"npi":[1699081224]}]}]}]},{"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":"273080192"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":47.76,"billing_code_modifier":["59"],"providers":[{"billed_charge":62.00,"npi":[1518330927]}]}]}]},{"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":"273080192"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":56.33,"billing_code_modifier":["  "],"providers":[{"billed_charge":96.00,"npi":[1518330927]},{"billed_charge":96.00,"npi":[1699081224]}]}]}]},{"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":"273080192"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":32.39,"billing_code_modifier":["  "],"providers":[{"billed_charge":65.00,"npi":[1518330927]},{"billed_charge":65.00,"npi":[1699081224]}]}]}]}]}
