{"reporting_entity_name":"Allegiance Benefit Plan Mgmt","reporting_entity_type":"third party","last_updated_on":"2026-09-30","version":"2.0.0","out_of_network":[{"name":"PSYTX COMPLEX INTERACTIVE","billing_code_type":"CPT","billing_code":"90785","billing_code_type_version":"2026","description":"PSYTX COMPLEX INTERACTIVE","allowed_amounts":[{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":16.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":20.00,"npi":[1083399125]},{"billed_charge":20.00,"npi":[1487424321]},{"billed_charge":20.00,"npi":[1518736438]},{"billed_charge":20.00,"npi":[1598304255]},{"billed_charge":20.00,"npi":[1730952359]},{"billed_charge":20.00,"npi":[1831866441]},{"billed_charge":20.00,"npi":[1891512166]}]},{"allowed_amount":16.35,"billing_code_modifier":["XE"],"providers":[{"billed_charge":20.00,"npi":[1518736438]},{"billed_charge":20.00,"npi":[1598552069]}]}]}]},{"name":"PSYTX W PT 30 MINUTES","billing_code_type":"CPT","billing_code":"90832","billing_code_type_version":"2026","description":"PSYTX W PT 30 MINUTES","allowed_amounts":[{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":64.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":80.00,"npi":[1083399125]},{"billed_charge":80.00,"npi":[1518736438]},{"billed_charge":80.00,"npi":[1730952359]}]},{"allowed_amount":64.04,"billing_code_modifier":["XE"],"providers":[{"billed_charge":80.05,"npi":[1083399125]},{"billed_charge":80.05,"npi":[1518736438]},{"billed_charge":80.05,"npi":[1598304255]},{"billed_charge":80.05,"npi":[1730952359]},{"billed_charge":80.05,"npi":[1831866441]}]},{"allowed_amount":65.45,"billing_code_modifier":["XE"],"providers":[{"billed_charge":80.05,"npi":[1518736438]},{"billed_charge":80.05,"npi":[1598552069]}]}]}]},{"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":"880752804"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":200.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":200.00,"npi":[1881657427]}]}]}]},{"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":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":128.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1487424321]},{"billed_charge":160.00,"npi":[1831866441]},{"billed_charge":160.00,"npi":[1891512166]}]}]},{"tin":{"type":"npi","value":"813173174"},"service_code":["10"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":160.00,"billing_code_modifier":["95"],"providers":[{"billed_charge":160.00,"npi":[1356793749]}]}]},{"tin":{"type":"npi","value":"813173174"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":160.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":160.00,"npi":[1356793749]}]}]},{"tin":{"type":"npi","value":"854269543"},"service_code":["02"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":100.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":100.00,"npi":[1104365493]},{"billed_charge":100.00,"npi":[1295323343]}]}]},{"tin":{"type":"npi","value":"854269543"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":100.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":100.00,"npi":[1104365493]}]}]},{"tin":{"type":"npi","value":"994282526"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":200.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":200.00,"npi":[1457949216]}]}]}]},{"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":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":38.23,"billing_code_modifier":["XE"],"providers":[{"billed_charge":50.00,"npi":[1518736438]}]},{"allowed_amount":40.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":50.00,"npi":[1083399125]},{"billed_charge":50.00,"npi":[1518736438]},{"billed_charge":50.00,"npi":[1598552069]},{"billed_charge":50.00,"npi":[1730952359]},{"billed_charge":50.05,"npi":[1730952359]}]},{"allowed_amount":40.01,"billing_code_modifier":["XE"],"providers":[{"billed_charge":50.00,"npi":[1083399125]},{"billed_charge":50.00,"npi":[1487424321]},{"billed_charge":50.00,"npi":[1598552069]},{"billed_charge":50.00,"npi":[1730952359]},{"billed_charge":50.05,"npi":[1083399125]},{"billed_charge":50.05,"npi":[1487424321]},{"billed_charge":50.05,"npi":[1730952359]}]}]},{"tin":{"type":"npi","value":"854269543"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":55.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":55.00,"npi":[1104365493]},{"billed_charge":55.00,"npi":[1295323343]}]}]}]},{"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":"260725962"},"service_code":["12"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":74.66,"billing_code_modifier":["  "],"providers":[{"billed_charge":177.76,"npi":[1033762356]},{"billed_charge":177.76,"npi":[1669534731]},{"billed_charge":177.76,"npi":[1942040597]}]}]},{"tin":{"type":"npi","value":"264073962"},"service_code":["*F"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":104.00,"billing_code_modifier":["GN"],"providers":[{"billed_charge":160.00,"npi":[1649933623]}]}]},{"tin":{"type":"npi","value":"264073962"},"service_code":["*V"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":104.00,"billing_code_modifier":["GN"],"providers":[{"billed_charge":160.00,"npi":[1649933623]}]}]},{"tin":{"type":"npi","value":"264073962"},"service_code":["12"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":104.00,"billing_code_modifier":["GN"],"providers":[{"billed_charge":160.00,"npi":[1013294651]},{"billed_charge":160.00,"npi":[1649933623]}]}]},{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":80.04,"billing_code_modifier":["XE"],"providers":[{"billed_charge":100.05,"npi":[1003643719]},{"billed_charge":100.05,"npi":[1154916377]},{"billed_charge":100.05,"npi":[1275074916]},{"billed_charge":100.05,"npi":[1295352490]},{"billed_charge":100.05,"npi":[1326928854]},{"billed_charge":100.05,"npi":[1528296944]},{"billed_charge":100.05,"npi":[1689690257]}]},{"allowed_amount":109.05,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1528296944]},{"billed_charge":160.00,"npi":[1659881324]}]},{"allowed_amount":109.10,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1154916377]},{"billed_charge":160.00,"npi":[1689690257]}]},{"allowed_amount":160.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1154916377]},{"billed_charge":160.00,"npi":[1205675485]},{"billed_charge":160.00,"npi":[1215620919]},{"billed_charge":160.00,"npi":[1225855653]},{"billed_charge":160.00,"npi":[1295352490]},{"billed_charge":160.00,"npi":[1326928854]},{"billed_charge":160.00,"npi":[1407533342]},{"billed_charge":160.00,"npi":[1548863087]},{"billed_charge":160.00,"npi":[1659881324]}]}]}]},{"name":"Swallowing\/oral function treat","billing_code_type":"CPT","billing_code":"92526","billing_code_type_version":"2026","description":"Swallowing\/oral function treat","allowed_amounts":[{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":120.65,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1154916377]}]},{"allowed_amount":128.04,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1295352490]},{"billed_charge":160.05,"npi":[1225855653]},{"billed_charge":160.05,"npi":[1295352490]}]},{"allowed_amount":160.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1154916377]},{"billed_charge":160.00,"npi":[1295352490]},{"billed_charge":160.00,"npi":[1407533342]},{"billed_charge":160.00,"npi":[1689413825]}]},{"allowed_amount":160.05,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.05,"npi":[1154916377]},{"billed_charge":160.05,"npi":[1255779849]},{"billed_charge":160.05,"npi":[1295352490]},{"billed_charge":160.05,"npi":[1407533342]},{"billed_charge":160.05,"npi":[1528296944]}]}]}]},{"name":"Tx serv, use of speech gen dev","billing_code_type":"CPT","billing_code":"92609","billing_code_type_version":"2026","description":"Tx serv, use of speech gen dev","allowed_amounts":[{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":146.90,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1154916377]},{"billed_charge":160.00,"npi":[1689690257]}]},{"allowed_amount":146.95,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1528296944]},{"billed_charge":160.00,"npi":[1659881324]}]}]}]},{"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":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":32.04,"billing_code_modifier":["XE"],"providers":[{"billed_charge":40.05,"npi":[1023841210]},{"billed_charge":40.05,"npi":[1326663550]}]}]}]},{"name":"Group therapeutic procedure(s)","billing_code_type":"CPT","billing_code":"97150","billing_code_type_version":"2026","description":"Group therapeutic procedure(s)","allowed_amounts":[{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":20.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":25.00,"npi":[1245119734]},{"billed_charge":25.00,"npi":[1659156016]}]},{"allowed_amount":20.04,"billing_code_modifier":["XE"],"providers":[{"billed_charge":25.05,"npi":[1245119734]},{"billed_charge":25.05,"npi":[1427652833]},{"billed_charge":25.05,"npi":[1508130113]},{"billed_charge":25.05,"npi":[1538932355]},{"billed_charge":25.05,"npi":[1659156016]},{"billed_charge":25.05,"npi":[1750114351]},{"billed_charge":25.05,"npi":[1831780444]},{"billed_charge":25.05,"npi":[1851260665]},{"billed_charge":25.05,"npi":[1902314826]},{"billed_charge":25.05,"npi":[1972283240]}]}]}]},{"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":"364282716"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":398.40,"billing_code_modifier":["HN"],"providers":[{"billed_charge":398.40,"npi":[1902629579]}]}]},{"tin":{"type":"npi","value":"364282716"},"service_code":["12"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":398.40,"billing_code_modifier":["HN"],"providers":[{"billed_charge":398.40,"npi":[1902629579]}]}]},{"tin":{"type":"npi","value":"474290599"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":80.00,"billing_code_modifier":["HN"],"providers":[{"billed_charge":80.00,"npi":[1457906265]}]}]},{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":80.00,"billing_code_modifier":["HN"],"providers":[{"billed_charge":80.00,"npi":[1275074916]},{"billed_charge":80.00,"npi":[1457906265]},{"billed_charge":80.00,"npi":[1699341883]}]},{"allowed_amount":80.00,"billing_code_modifier":["HO"],"providers":[{"billed_charge":80.00,"npi":[1275074916]},{"billed_charge":80.00,"npi":[1457906265]},{"billed_charge":80.00,"npi":[1699341883]}]},{"allowed_amount":160.00,"billing_code_modifier":["HM"],"providers":[{"billed_charge":160.00,"npi":[1275074916]},{"billed_charge":160.00,"npi":[1326554296]},{"billed_charge":160.00,"npi":[1457906265]},{"billed_charge":160.00,"npi":[1699341883]}]},{"allowed_amount":160.00,"billing_code_modifier":["HN"],"providers":[{"billed_charge":160.00,"npi":[1275074916]},{"billed_charge":160.00,"npi":[1326554296]},{"billed_charge":160.00,"npi":[1457906265]},{"billed_charge":160.00,"npi":[1699341883]}]},{"allowed_amount":160.00,"billing_code_modifier":["HO"],"providers":[{"billed_charge":160.00,"npi":[1275074916]},{"billed_charge":160.00,"npi":[1326554296]},{"billed_charge":160.00,"npi":[1457906265]},{"billed_charge":160.00,"npi":[1699341883]}]},{"allowed_amount":240.00,"billing_code_modifier":["HN"],"providers":[{"billed_charge":240.00,"npi":[1275074916]},{"billed_charge":240.00,"npi":[1326554296]},{"billed_charge":240.00,"npi":[1457906265]},{"billed_charge":240.00,"npi":[1699341883]}]},{"allowed_amount":240.00,"billing_code_modifier":["HO"],"providers":[{"billed_charge":240.00,"npi":[1275074916]},{"billed_charge":240.00,"npi":[1326554296]},{"billed_charge":240.00,"npi":[1457906265]},{"billed_charge":240.00,"npi":[1699341883]}]},{"allowed_amount":240.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":240.00,"npi":[1275074916]},{"billed_charge":240.00,"npi":[1326554296]},{"billed_charge":240.00,"npi":[1457906265]},{"billed_charge":240.00,"npi":[1699341883]}]},{"allowed_amount":320.00,"billing_code_modifier":["HN"],"providers":[{"billed_charge":320.00,"npi":[1275074916]},{"billed_charge":320.00,"npi":[1326554296]},{"billed_charge":320.00,"npi":[1699341883]}]},{"allowed_amount":320.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":320.00,"npi":[1275074916]},{"billed_charge":320.00,"npi":[1326554296]},{"billed_charge":320.00,"npi":[1699341883]}]},{"allowed_amount":560.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":560.00,"npi":[1326554296]},{"billed_charge":560.00,"npi":[1588030621]}]}]}]},{"name":"ADAPT BEHAVIOR TX PHYS\/QHP","billing_code_type":"CPT","billing_code":"97155","billing_code_type_version":"2026","description":"ADAPT BEHAVIOR TX PHYS\/QHP","allowed_amounts":[{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":160.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1275074916]},{"billed_charge":160.00,"npi":[1326554296]},{"billed_charge":160.00,"npi":[1457906265]},{"billed_charge":160.00,"npi":[1588030621]},{"billed_charge":160.00,"npi":[1699341883]}]}]}]},{"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":"208595133"},"service_code":["12"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":260.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":260.00,"npi":[1215645981]}]},{"allowed_amount":260.00,"billing_code_modifier":["KX"],"providers":[{"billed_charge":260.00,"npi":[1215645981]}]}]},{"tin":{"type":"npi","value":"465696517"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":110.00,"billing_code_modifier":["GO"],"providers":[{"billed_charge":200.00,"npi":[1023614120]},{"billed_charge":200.00,"npi":[1194553669]},{"billed_charge":200.00,"npi":[1245729938]},{"billed_charge":200.00,"npi":[1336536903]},{"billed_charge":200.00,"npi":[1396940631]},{"billed_charge":200.00,"npi":[1447792684]},{"billed_charge":200.00,"npi":[1649640806]},{"billed_charge":200.00,"npi":[1659912822]}]},{"allowed_amount":110.00,"billing_code_modifier":["GP"],"providers":[{"billed_charge":200.00,"npi":[1023614120]},{"billed_charge":200.00,"npi":[1194553669]},{"billed_charge":200.00,"npi":[1245729938]},{"billed_charge":200.00,"npi":[1336536903]},{"billed_charge":200.00,"npi":[1396940631]},{"billed_charge":200.00,"npi":[1447792684]},{"billed_charge":200.00,"npi":[1649640806]},{"billed_charge":200.00,"npi":[1659912822]}]},{"allowed_amount":110.00,"billing_code_modifier":["XP"],"providers":[{"billed_charge":200.00,"npi":[1023614120]},{"billed_charge":200.00,"npi":[1194553669]},{"billed_charge":200.00,"npi":[1245729938]},{"billed_charge":200.00,"npi":[1336536903]},{"billed_charge":200.00,"npi":[1396940631]},{"billed_charge":200.00,"npi":[1447792684]},{"billed_charge":200.00,"npi":[1649640806]},{"billed_charge":200.00,"npi":[1659912822]}]}]},{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":32.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":40.00,"npi":[1245119734]},{"billed_charge":40.00,"npi":[1508130113]},{"billed_charge":40.00,"npi":[1558041640]},{"billed_charge":40.00,"npi":[1659156016]},{"billed_charge":40.00,"npi":[1750114351]},{"billed_charge":40.00,"npi":[1851260665]}]},{"allowed_amount":32.04,"billing_code_modifier":["XE"],"providers":[{"billed_charge":40.05,"npi":[1245119734]},{"billed_charge":40.05,"npi":[1427652833]},{"billed_charge":40.05,"npi":[1508130113]},{"billed_charge":40.05,"npi":[1659156016]},{"billed_charge":40.05,"npi":[1750114351]}]},{"allowed_amount":128.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":160.00,"npi":[1376208421]},{"billed_charge":160.00,"npi":[1508130113]},{"billed_charge":160.00,"npi":[1699665190]},{"billed_charge":160.00,"npi":[1750114351]}]},{"allowed_amount":160.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":200.00,"npi":[1508130113]},{"billed_charge":200.00,"npi":[1659156016]}]}]},{"tin":{"type":"npi","value":"834607811"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":124.05,"billing_code_modifier":["GO"],"providers":[{"billed_charge":152.28,"npi":[1902545056]}]}]}]},{"name":"Med Nutrition Indiv Subseq","billing_code_type":"CPT","billing_code":"97803","billing_code_type_version":"2026","description":"Med Nutrition Indiv Subseq","allowed_amounts":[{"tin":{"type":"npi","value":"474290599"},"service_code":["49"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":64.00,"billing_code_modifier":["XE"],"providers":[{"billed_charge":80.00,"npi":[1043903198]}]}]}]}]}
