{
  "reporting_entity_name" : "Baylor Scott & White Insurance Company",
  "reporting_entity_type" : "Health Insurer",
  "last_updated_on" : "2026-11-01",
  "version" : "2.0.0",
  "out_of_network" : [ {
    "name" : "DIALYSIS PROCEDURE",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2026",
    "billing_code" : "90999",
    "description" : "Unlisted dialysis procedure, inpatient or outpatient",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "11-2226275"
      },
      "billing_class" : "institutional",
      "setting" : "outpatient",
      "payments" : [ {
        "allowed_amount" : 600.00,
        "billing_code_modifier" : [ "G4", "V5" ],
        "providers" : [ {
          "billed_charge" : 8832.00,
          "npi" : [ 1639582653 ]
        } ]
      }, {
        "allowed_amount" : 600.00,
        "billing_code_modifier" : [ "G5", "V5" ],
        "providers" : [ {
          "billed_charge" : 8832.00,
          "npi" : [ 1639582653 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "Adaptive behavior treatment by pro",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2026",
    "billing_code" : "97153",
    "description" : "Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "85-3970595"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "setting" : "outpatient",
      "payments" : [ {
        "allowed_amount" : 200.00,
        "providers" : [ {
          "billed_charge" : 293.28,
          "npi" : [ 1033792031 ]
        } ]
      }, {
        "allowed_amount" : 175.00,
        "providers" : [ {
          "billed_charge" : 256.62,
          "npi" : [ 1033792031 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "Group adaptive behavior treatment",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2026",
    "billing_code" : "97154",
    "description" : "Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "85-3970595"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "setting" : "outpatient",
      "payments" : [ {
        "allowed_amount" : 16.00,
        "providers" : [ {
          "billed_charge" : 17.78,
          "npi" : [ 1033792031 ]
        } ]
      }, {
        "allowed_amount" : 128.00,
        "providers" : [ {
          "billed_charge" : 142.24,
          "npi" : [ 1033792031 ]
        } ]
      } ]
    } ]
  } ]
}