{
  "reporting_entity_name" : "HealthPlanName",
  "reporting_entity_type" : "HealthPlanType",
  "last_updated_on" : "2025-03-28",
  "version" : "1.0.0",
  "out_of_network" : [ {
    "name" : "INFLUENZA ASSAY W/OPTIC",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2023",
    "billing_code" : "87804",
    "description" : "Infectious agent antigen detection by immunoassay with direct optical observation; Influenza",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "47-3138368"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "QW" ],
        "providers" : [ {
          "billed_charge" : 40.00,
          "npi" : [ 1780847327 ]
        } ]
      }, {
        "allowed_amount" : 16.55,
        "billing_code_modifier" : [ "59", "QW" ],
        "providers" : [ {
          "billed_charge" : 40.00,
          "npi" : [ 1780847327 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "EXTERNAL COUNTERPULSATION PER TREATMENT SESSION",
    "billing_code_type" : "HCPCS",
    "billing_code_type_version" : "2023",
    "billing_code" : "G0166",
    "description" : "External counterpulsation, per treatment session",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "27-3236103"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 540.00,
        "providers" : [ {
          "billed_charge" : 900.00,
          "npi" : [ 1003080375 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "NEUROMUSCULAR REEDUCATION",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2023",
    "billing_code" : "97112",
    "description" : "Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "85-2448741"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 50.86,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 92.00,
          "npi" : [ 1902327794 ]
        }, {
          "billed_charge" : 100.00,
          "npi" : [ 1902327794 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "OFFICE/OUTPATIENT VISIT EST",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2023",
    "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" : "75-2510007"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 201.00,
        "providers" : [ {
          "billed_charge" : 334.00,
          "npi" : [ 1770048704 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "THERAPEUTIC ACTIVITIES",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2023",
    "billing_code" : "97530",
    "description" : "Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "85-2448741"
      },
      "service_code" : [ "11" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 62.60,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 100.00,
          "npi" : [ 1902327794 ]
        } ]
      }, {
        "allowed_amount" : 51.80,
        "billing_code_modifier" : [ "GP" ],
        "providers" : [ {
          "billed_charge" : 100.00,
          "npi" : [ 1902327794 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "DIALYSIS PROCEDURE",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2023",
    "billing_code" : "90999",
    "description" : "Unlisted dialysis procedure, inpatient or outpatient",
    "allowed_amounts" : [ {
      "tin" : {
        "type" : "ein",
        "value" : "87-4771692"
      },
      "billing_class" : "institutional",
      "payments" : [ {
        "allowed_amount" : 420.00,
        "providers" : [ {
          "billed_charge" : 4341.00,
          "npi" : [ 1225783186 ]
        } ]
      }, {
        "allowed_amount" : 128.36,
        "providers" : [ {
          "billed_charge" : 4341.00,
          "npi" : [ 1225783186 ]
        } ]
      }, {
        "allowed_amount" : 127.91,
        "providers" : [ {
          "billed_charge" : 4341.00,
          "npi" : [ 1225783186 ]
        } ]
      } ]
    } ]
  }, {
    "name" : "OFFICE/OUTPATIENT VISIT NEW",
    "billing_code_type" : "CPT",
    "billing_code_type_version" : "2023",
    "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" : "75-2510007"
      },
      "service_code" : [ "20" ],
      "billing_class" : "professional",
      "payments" : [ {
        "allowed_amount" : 201.00,
        "providers" : [ {
          "billed_charge" : 503.00,
          "npi" : [ 1770048704 ]
        } ]
      }, {
        "allowed_amount" : 167.58,
        "providers" : [ {
          "billed_charge" : 503.00,
          "npi" : [ 1770048704 ]
        } ]
      } ]
    } ]
  } ]
}