{"reporting_entity_name":"Allegiance Benefit Plan Mgmt","reporting_entity_type":"third party","last_updated_on":"2026-11-01","version":"2.0.0","out_of_network":[{"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":"923655945"},"service_code":["03"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":128.49,"billing_code_modifier":["  "],"providers":[{"billed_charge":150.00,"npi":[1043972045]},{"billed_charge":150.00,"npi":[1114806353]},{"billed_charge":150.00,"npi":[1407477763]},{"billed_charge":150.00,"npi":[1730971078]}]}]},{"tin":{"type":"npi","value":"923655945"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":128.49,"billing_code_modifier":["  "],"providers":[{"billed_charge":150.00,"npi":[1407477763]}]}]}]},{"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":"923655945"},"service_code":["03"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":170.39,"billing_code_modifier":["  "],"providers":[{"billed_charge":225.00,"npi":[1043972045]},{"billed_charge":225.00,"npi":[1114806353]},{"billed_charge":225.00,"npi":[1326890211]},{"billed_charge":225.00,"npi":[1730971078]}]}]},{"tin":{"type":"npi","value":"923655945"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":170.39,"billing_code_modifier":["  "],"providers":[{"billed_charge":225.00,"npi":[1043972045]},{"billed_charge":225.00,"npi":[1407477763]},{"billed_charge":225.00,"npi":[1730971078]}]}]}]},{"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":"883267567"},"service_code":["10"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":250.00,"billing_code_modifier":["GT"],"providers":[{"billed_charge":250.00,"npi":[1861510224]}]}]},{"tin":{"type":"npi","value":"883267567"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":250.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":250.00,"npi":[1457968562]},{"billed_charge":250.00,"npi":[1477392553]},{"billed_charge":250.00,"npi":[1861510224]}]}]},{"tin":{"type":"npi","value":"992011082"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":250.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":250.00,"npi":[1003328543]},{"billed_charge":250.00,"npi":[1174926141]},{"billed_charge":250.00,"npi":[1649868860]},{"billed_charge":250.00,"npi":[1700367158]}]}]}]},{"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":"263024567"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":50.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":50.00,"npi":[1063683159]}]}]},{"tin":{"type":"npi","value":"911787654"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":57.38,"billing_code_modifier":["  "],"providers":[{"billed_charge":94.00,"npi":[1588325260]},{"billed_charge":94.00,"npi":[1831785385]},{"billed_charge":94.00,"npi":[1861677783]}]}]}]},{"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":"263024567"},"service_code":["11"],"billing_class":"professional","setting":"outpatient","payments":[{"allowed_amount":20.00,"billing_code_modifier":["  "],"providers":[{"billed_charge":20.00,"npi":[1063683159]}]}]}]}]}
