{
	"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": "2230102",
	"plan_market_type": "group",
	"last_updated_on": "2026-04-08",
	"version": "2.0.1",
	"out_of_network":[{
		"name": "PR ADAPTIVE BEHAVIOR TX BY TECH",
		"billing_code_type": "CPT",
		"billing_code_type_version": "2026",
		"billing_code": "97153",
		"description": "Adaptive Behavior Tx by Tech",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "931517179"
			},
			"service_code": ["12"],
			"billing_class": "professional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 1000.00,
					"npi": [1790341097]
				},{
					"billed_charge": 1350.00,
					"npi": [1790341097]
				},{
					"billed_charge": 1500.00,
					"npi": [1790341097]
				},{
					"billed_charge": 900.00,
					"npi": [1790341097]
				}]
			},{
				"allowed_amount": 162.00,
				"providers":[{
					"billed_charge": 900.00,
					"npi": [1790341097]
				}]
			},{
				"allowed_amount": 180.00,
				"providers":[{
					"billed_charge": 1000.00,
					"npi": [1053005645,1790341097]
				}]
			},{
				"allowed_amount": 202.50,
				"providers":[{
					"billed_charge": 1125.00,
					"npi": [1053005645]
				}]
			},{
				"allowed_amount": 243.00,
				"providers":[{
					"billed_charge": 1350.00,
					"npi": [1053005645,1790341097]
				}]
			},{
				"allowed_amount": 270.00,
				"providers":[{
					"billed_charge": 1500.00,
					"npi": [1053005645,1790341097]
				}]
			},{
				"allowed_amount": 324.00,
				"providers":[{
					"billed_charge": 1800.00,
					"npi": [1053005645]
				}]
			},{
				"allowed_amount": 360.00,
				"providers":[{
					"billed_charge": 2000.00,
					"npi": [1053005645,1790341097]
				}]
			}]
		}]
	}]
}