{
	"reporting_entity_name": "Hometown Health",
	"reporting_entity_type": "Group Health Plan",
	"issuer_name": "HTH Providers",
	"plan_name": "HOMETOWN HEALTH PROVIDERS: HTH PROVIDERS",
	"plan_id_type": "HIOS",
	"plan_id": "2370114",
	"plan_market_type": "group",
	"last_updated_on": "2026-03-08",
	"version": "2.0.1",
	"out_of_network":[{
		"name": "PR THERAPEUTIC ACTIVITIES",
		"billing_code_type": "CPT",
		"billing_code_type_version": "2025",
		"billing_code": "97530",
		"description": "Therapeutic Activities",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "823255983"
			},
			"service_code": ["11"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 36.15,
				"billing_code_modifier": ["GP", "59"],
				"providers":[{
					"billed_charge": 92.00,
					"npi": [1407471378]
				}]
			},{
				"allowed_amount": 36.15,
				"billing_code_modifier": ["GP", "59", "CQ"],
				"providers":[{
					"billed_charge": 92.00,
					"npi": [1407471378]
				}]
			},{
				"allowed_amount": 108.45,
				"billing_code_modifier": ["GP", "59"],
				"providers":[{
					"billed_charge": 276.00,
					"npi": [1407471378]
				}]
			},{
				"allowed_amount": 108.45,
				"billing_code_modifier": ["GP", "59", "CQ"],
				"providers":[{
					"billed_charge": 276.00,
					"npi": [1407471378]
				}]
			},{
				"allowed_amount": 72.30,
				"billing_code_modifier": ["GP", "59"],
				"providers":[{
					"billed_charge": 184.00,
					"npi": [1407471378]
				}]
			},{
				"allowed_amount": 72.30,
				"billing_code_modifier": ["GP", "59", "CQ"],
				"providers":[{
					"billed_charge": 184.00,
					"npi": [1407471378]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "932142801"
			},
			"service_code": ["11"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 36.15,
				"billing_code_modifier": ["59"],
				"providers":[{
					"billed_charge": 52.00,
					"npi": [1134643885]
				}]
			},{
				"allowed_amount": 36.15,
				"providers":[{
					"billed_charge": 52.00,
					"npi": [1134643885]
				}]
			}]
		}]
	}]
}
