{
  "reporting_entity_name" : "HealthPlan",
  "reporting_entity_type" : "HealthPlan",
  "last_updated_on" : "2026-06-01",
  "version" : "1.0.0",
  "out_of_network" : [ {
    "name" : "UNDESIGNATED CODE",
    "billing_code_type" : "HCPCS",
    "billing_code_type_version" : "2024",
    "billing_code" : "J3490",
    "description" : "UNDESIGNATED CODE",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "81-2792506"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 1335.00,
        "providers" : [ {
          "billed_charge" : 1335.00,
          "npi" : [ 1427251107 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "OFFICE/OUTPATIENT VISIT EST",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2024",
    "billing_code" : "99214",
    "description" : "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "26-3614788"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 127.13,
        "providers" : [ {
          "billed_charge" : 200.00,
          "npi" : [ 1619950359 ]
        } ]
      }, {
        "allowed_amount" : 135.48,
        "providers" : [ {
          "billed_charge" : 200.00,
          "npi" : [ 1619950359 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "47-0958788"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 131.39,
        "providers" : [ {
          "billed_charge" : 206.00,
          "npi" : [ 1760723209 ]
        } ]
      }, {
        "allowed_amount" : 142.29,
        "providers" : [ {
          "billed_charge" : 206.00,
          "npi" : [ 1760723209 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "93-4543755"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 121.66,
        "providers" : [ {
          "billed_charge" : 368.00,
          "npi" : [ 1477683886 ]
        } ]
      }, {
        "allowed_amount" : 131.75,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 396.00,
          "npi" : [ 1477683886 ]
        }, {
          "billed_charge" : 368.00,
          "npi" : [ 1477683886 ]
        } ]
      }, {
        "allowed_amount" : 131.75,
        "billing_code_modifier" : [ "95" ],
        "providers" : [ {
          "billed_charge" : 368.00,
          "npi" : [ 1477683886 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "82-1977126"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 121.66,
        "providers" : [ {
          "billed_charge" : 377.00,
          "npi" : [ 1194146399 ]
        } ]
      }, {
        "allowed_amount" : 131.75,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 377.00,
          "npi" : [ 1194146399 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "82-0647491"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 125.67,
        "providers" : [ {
          "billed_charge" : 200.00,
          "npi" : [ 1578726154 ]
        } ]
      }, {
        "allowed_amount" : 135.25,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 200.00,
          "npi" : [ 1578726154 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "86-1429247"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 125.67,
        "providers" : [ {
          "billed_charge" : 250.00,
          "npi" : [ 1083920888 ]
        }, {
          "billed_charge" : 300.00,
          "npi" : [ 1083920888 ]
        } ]
      }, {
        "allowed_amount" : 135.25,
        "providers" : [ {
          "billed_charge" : 250.00,
          "npi" : [ 1083920888 ]
        }, {
          "billed_charge" : 300.00,
          "npi" : [ 1083920888 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "82-0647491"
      },
      "service_code" : [ "10" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 135.25,
        "billing_code_modifier" : [ "95" ],
        "providers" : [ {
          "billed_charge" : 200.00,
          "npi" : [ 1578726154 ]
        } ]
      }, {
        "allowed_amount" : 125.67,
        "billing_code_modifier" : [ "95" ],
        "providers" : [ {
          "billed_charge" : 200.00,
          "npi" : [ 1578726154 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "47-3138368"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 125.67,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 163.00,
          "npi" : [ 1780847327 ]
        } ]
      }, {
        "allowed_amount" : 135.25,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 163.00,
          "npi" : [ 1780847327 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "OFFICE/OUTPATIENT VISIT EST",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2024",
    "billing_code" : "99213",
    "description" : "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "93-4543755"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 86.34,
        "providers" : [ {
          "billed_charge" : 260.00,
          "npi" : [ 1477683886 ]
        } ]
      }, {
        "allowed_amount" : 92.41,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 278.00,
          "npi" : [ 1477683886 ]
        }, {
          "billed_charge" : 260.00,
          "npi" : [ 1477683886 ]
        } ]
      }, {
        "allowed_amount" : 92.41,
        "billing_code_modifier" : [ "95" ],
        "providers" : [ {
          "billed_charge" : 260.00,
          "npi" : [ 1477683886 ]
        }, {
          "billed_charge" : 278.00,
          "npi" : [ 1477683886 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "26-3614788"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 95.09,
        "providers" : [ {
          "billed_charge" : 150.00,
          "npi" : [ 1619950359 ]
        } ]
      }, {
        "allowed_amount" : 90.33,
        "providers" : [ {
          "billed_charge" : 150.00,
          "npi" : [ 1619950359 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "82-4128625"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 86.34,
        "providers" : [ {
          "billed_charge" : 230.00,
          "npi" : [ 1033617931 ]
        } ]
      }, {
        "allowed_amount" : 92.41,
        "providers" : [ {
          "billed_charge" : 230.00,
          "npi" : [ 1033617931 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "OFFICE/OUTPATIENT VISIT EST",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2024",
    "billing_code" : "99215",
    "description" : "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "82-0647491"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 176.35,
        "providers" : [ {
          "billed_charge" : 250.00,
          "npi" : [ 1578726154 ]
        } ]
      }, {
        "allowed_amount" : 191.87,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 250.00,
          "npi" : [ 1578726154 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "82-0647491"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 176.35,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 250.00,
          "npi" : [ 1578726154 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "OFFICE/OUTPATIENT VISIT NEW",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2024",
    "billing_code" : "99204",
    "description" : "Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "82-1977126"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 158.91,
        "providers" : [ {
          "billed_charge" : 489.00,
          "npi" : [ 1194146399 ]
        } ]
      }, {
        "allowed_amount" : 172.37,
        "billing_code_modifier" : [ "25" ],
        "providers" : [ {
          "billed_charge" : 489.00,
          "npi" : [ 1194146399 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "THER/PROPH/DIAG INJ SC/IM",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2025",
    "billing_code" : "96372",
    "description" : "Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "82-1977126"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 13.44,
        "providers" : [ {
          "billed_charge" : 43.00,
          "npi" : [ 1194146399 ]
        } ]
      }, {
        "allowed_amount" : 14.86,
        "providers" : [ {
          "billed_charge" : 43.00,
          "npi" : [ 1194146399 ]
        } ]
      }, {
        "allowed_amount" : 26.88,
        "providers" : [ {
          "billed_charge" : 86.00,
          "npi" : [ 1194146399 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "THERAPEUTIC EXERCISES",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2024",
    "billing_code" : "97110",
    "description" : "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "27-3815440"
      },
      "billing_class" : "institutional",
      "payments" : [ {
        "allowed_amount" : 51.01,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 656.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 51.36,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 656.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 22.27,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 328.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 29.01,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 328.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 22.00,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 328.00,
          "npi" : [ 1851632616 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "HYPERBARIC OXYGEN THERAPY",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2025",
    "billing_code" : "99183",
    "description" : "Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "46-4078404"
      },
      "service_code" : [ "22" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 110.56,
        "providers" : [ {
          "billed_charge" : 450.00,
          "npi" : [ 1821023003 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "Guidance for localization of target volume for",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2025",
    "billing_code" : "77387",
    "description" : "Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "75-2402478"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 35.66,
        "providers" : [ {
          "billed_charge" : 298.00,
          "npi" : [ 1689675902 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "MANUAL THERAPY 1/> REGIONS",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2024",
    "billing_code" : "97140",
    "description" : "Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "27-3815440"
      },
      "billing_class" : "institutional",
      "payments" : [ {
        "allowed_amount" : 41.72,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 1000.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 62.58,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 1500.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 42.54,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 1000.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 63.81,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 1500.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 21.27,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 500.00,
          "npi" : [ 1851632616 ]
        } ]
      }, {
        "allowed_amount" : 20.86,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 500.00,
          "npi" : [ 1851632616 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "INFLUENZA ASSAY W/OPTIC",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2025",
    "billing_code" : "87804",
    "description" : "Infectious agent antigen detection by immunoassay with direct optical observation; Influenza",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "47-0958788"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "QW" ],
        "providers" : [ {
          "billed_charge" : 27.00,
          "npi" : [ 1760723209 ]
        } ]
      }, {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "59", "QW" ],
        "providers" : [ {
          "billed_charge" : 27.00,
          "npi" : [ 1760723209 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "82-1977126"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "QW" ],
        "providers" : [ {
          "billed_charge" : 50.00,
          "npi" : [ 1194146399 ]
        } ]
      }, {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "59", "QW" ],
        "providers" : [ {
          "billed_charge" : 50.00,
          "npi" : [ 1194146399 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "47-3138368"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "QW" ],
        "providers" : [ {
          "billed_charge" : 35.00,
          "npi" : [ 1780847327 ]
        } ]
      }, {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "59", "QW" ],
        "providers" : [ {
          "billed_charge" : 35.00,
          "npi" : [ 1780847327 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "82-4128625"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "QW" ],
        "providers" : [ {
          "billed_charge" : 39.00,
          "npi" : [ 1033617931 ]
        } ]
      }, {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "59", "QW" ],
        "providers" : [ {
          "billed_charge" : 39.00,
          "npi" : [ 1033617931 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "URINALYSIS AUTO W/O SCOPE",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2024",
    "billing_code" : "81003",
    "description" : "Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "82-0647491"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 2.25,
        "billing_code_modifier" : [ "QW" ],
        "providers" : [ {
          "billed_charge" : 30.00,
          "npi" : [ 1578726154 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "UPR/LXTR ART STDY 3+ LVLS",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2024",
    "billing_code" : "93923",
    "description" : "Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia)",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "26-3614788"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 127.38,
        "providers" : [ {
          "billed_charge" : 250.00,
          "npi" : [ 1619950359 ]
        } ]
      }, {
        "allowed_amount" : 132.55,
        "billing_code_modifier" : [ "59" ],
        "providers" : [ {
          "billed_charge" : 250.00,
          "npi" : [ 1619950359 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "Radiation treatment delivery; Level 2, single-isoc",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2025",
    "billing_code" : "77407",
    "description" : "Radiation treatment delivery; Level 2, single-isocenter (eg, 3D or IMRT), photons, including imaging guidance, when performed",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "75-2402478"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 294.06,
        "providers" : [ {
          "billed_charge" : 894.00,
          "npi" : [ 1689675902 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "STREP A ASSAY W/OPTIC",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2025",
    "billing_code" : "87880",
    "description" : "Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "47-3138368"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 16.53,
        "billing_code_modifier" : [ "QW" ],
        "providers" : [ {
          "billed_charge" : 30.00,
          "npi" : [ 1780847327 ]
        } ]
      }, {
        "allowed_amount" : 16.53,
        "billing_code_modifier" : [ "59", "QW" ],
        "providers" : [ {
          "billed_charge" : 30.00,
          "npi" : [ 1780847327 ]
        } ]
      } ]
    }, {
      "tin" : {
        "type" : "ein",
        "value" : "82-1977126"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 16.53,
        "billing_code_modifier" : [ "QW" ],
        "providers" : [ {
          "billed_charge" : 50.00,
          "npi" : [ 1194146399 ]
        } ]
      } ]
    } ]
  } ]
}