{
	"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": "1040101",
	"plan_market_type": "group",
	"last_updated_on": "2026-07-08",
	"version": "2.0.1",
	"out_of_network":[{
		"name": "PHARMACY - GENERAL CLASSIFICATION",
		"billing_code_type": "RC",
		"billing_code_type_version": "2026",
		"billing_code": "0250",
		"description": "Pharmacy",
		"allowed_amounts":[{
			"tin": {
				"type": "ein",
				"value": "951643360"
			},
			"service_code": ["22"],
			"billing_class": "institutional",
			"payments":[{
				"allowed_amount": 0.00,
				"providers":[{
					"billed_charge": 23.01,
					"npi": [1992752315]
				},{
					"billed_charge": 24.44,
					"npi": [1992752315]
				},{
					"billed_charge": 114.15,
					"npi": [1992752315]
				},{
					"billed_charge": 11.00,
					"npi": [1992752315]
				},{
					"billed_charge": 13.00,
					"npi": [1992752315]
				},{
					"billed_charge": 17.50,
					"npi": [1992752315]
				},{
					"billed_charge": 22.00,
					"npi": [1992752315]
				},{
					"billed_charge": 26.00,
					"npi": [1992752315]
				},{
					"billed_charge": 33.00,
					"npi": [1992752315]
				},{
					"billed_charge": 39.00,
					"npi": [1992752315]
				},{
					"billed_charge": 5.00,
					"npi": [1992752315]
				}]
			}]
		}]
	}]
}