{
	"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": "9270102",
	"plan_market_type": "group",
	"last_updated_on": "2026-04-08",
	"version": "2.0.1",
	"out_of_network":[{
		"name": "PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN",
		"billing_code_type": "CPT",
		"billing_code_type_version": "2026",
		"billing_code": "99213",
		"description": "Office/Outpatient Established Low Mdm 20 Min",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "880058154"
			},
			"service_code": ["11", "02"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 75.18,
				"billing_code_modifier": ["25"],
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1720299472]
				}]
			},{
				"allowed_amount": 75.18,
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1720299472]
				}]
			},{
				"allowed_amount": 80.12,
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1720299472]
				}]
			},{
				"allowed_amount": 88.45,
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1396845921]
				}]
			},{
				"allowed_amount": 114.99,
				"billing_code_modifier": ["25"],
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1417744640]
				}]
			},{
				"allowed_amount": 114.99,
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1417744640]
				}]
			},{
				"allowed_amount": 123.16,
				"billing_code_modifier": ["25"],
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1417744640]
				}]
			},{
				"allowed_amount": 123.16,
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1417744640]
				}]
			},{
				"allowed_amount": 0.00,
				"billing_code_modifier": ["93"],
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1396845921]
				}]
			},{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 226.00,
					"npi": [1396845921]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "886005135"
			},
			"service_code": ["11"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 164.00,
					"npi": [1750529467]
				}]
			}]
		}]
	},{
		"name": "PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN",
		"billing_code_type": "CPT",
		"billing_code_type_version": "2026",
		"billing_code": "99214",
		"description": "Office/Outpatient Established Mod Mdm 30 Min",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "853652211"
			},
			"service_code": ["10"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 130.64,
				"billing_code_modifier": ["95"],
				"providers":[{
					"billed_charge": 175.00,
					"npi": [1538548516]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "880058154"
			},
			"service_code": ["11"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 105.76,
				"billing_code_modifier": ["25"],
				"providers":[{
					"billed_charge": 332.00,
					"npi": [1720299472]
				}]
			},{
				"allowed_amount": 105.76,
				"providers":[{
					"billed_charge": 332.00,
					"npi": [1720299472]
				}]
			},{
				"allowed_amount": 161.75,
				"billing_code_modifier": ["25"],
				"providers":[{
					"billed_charge": 332.00,
					"npi": [1417744640]
				}]
			},{
				"allowed_amount": 161.75,
				"providers":[{
					"billed_charge": 332.00,
					"npi": [1417744640]
				}]
			},{
				"allowed_amount": 175.36,
				"billing_code_modifier": ["25"],
				"providers":[{
					"billed_charge": 332.00,
					"npi": [1417744640]
				}]
			},{
				"allowed_amount": 175.36,
				"providers":[{
					"billed_charge": 332.00,
					"npi": [1417744640]
				}]
			}]
		},{
			"tin": {
				"type": "ein",
				"value": "886005135"
			},
			"service_code": ["11"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 136.86,
				"providers":[{
					"billed_charge": 266.00,
					"npi": [1275818270]
				}]
			}]
		}]
	}]
}