{
    "reporting_entity_name": "NOITU INSURANCE TRUST FUND",
    "reporting_entity_type": "GROUP HEALTH INSURANCE",
    "last_updated_on": "2026-02-17",
    "version": "1.0.0",
    "out_of_network":[
    { "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT PLA 2024 Q3",
    "billing_code": "0240U",
    "description": "Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "392598367"
       },
      "service_code": ["81"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 142.63,
        "providers": [{
          "billed_charge": 300.00,
          "npi": []
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "392563764"
      },
      "service_code": ["81"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 142.63,
        "providers": [{
          "billed_charge": 300.00,
          "npi": []
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "2022",
    "billing_code": "0905",
    "description": "Behavioral Health Treatments/Services (also see 091X, and extension of 090X) - Intensive outpatient services psychiatric ",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "364844689"
      },
      "service_code": ["89"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 47.00,
        "providers": [{
          "billed_charge": 4000.00,
          "npi": [1700328283]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "2022",
    "billing_code": "0915",
    "description": "Behavioral Health Treatments/Services Extension of 090X - Group therapy ",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "364844689"
      },
      "service_code": ["89"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 23.05,
        "providers": [{
          "billed_charge": 3125.00,
          "npi": [1700328283]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "76881",
    "description": "ULTRASOUND, COMPLETE JOINT (IE, JOINT SPACE AND PERI-ARTICULAR SOFT-TISSUE STRUCTURES), REAL-TIME WITH IMAGE DOCUMENTATION",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "832135557"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 73.23,
        "providers": [{
          "billed_charge": 350.00,
          "npi": [1093271306]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "80307",
    "description": "DRUG TEST(S), PRESUMPTIVE, ANY NUMBER OF DRUG CLASSES, ANY NUMBER OF DEVICES OR PROCEDURES; BY INSTRUMENT CHEMISTRY ANALYZERS (EG, UTILIZING IMMUNOASSAY [EG, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), CHROMATOGRAPHY (EG, GC, HPLC), AND MASS SPECTROMETRY EITHER WITH OR WITHOUT CHROMATOGRAPHY, (EG, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) INCLUDES SAMPLE VALIDATION WHEN PERFORMED, PER DATE OF SERVICE",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "465330784"
      },
      "service_code": ["81"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 75.00,
        "providers": [{
          "billed_charge": 75.00,
          "npi": []
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "800270103"
      },
      "service_code": ["81"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 108.13,
        "providers": [{
          "billed_charge": 186.14,
          "npi": []
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "84520",
    "description": "UREA NITROGEN; QUANTITATIVE",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "943357013"
      },
      "service_code": ["81"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 6.61,
        "providers": [{
          "billed_charge": 48.00,
          "npi": []
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "90834",
    "description": "PSYCHOTHERAPY, 45 MINUTES WITH PATIENT",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "921597475"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 142.51,
        "providers": [{
          "billed_charge": 350.00,
          "npi": [1225439219]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "90837",
    "description": "PSYCHOTHERAPY, 60 MINUTES WITH PATIENT",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "271620688"
      },
      "service_code": ["10", "11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 257.10,
        "providers": [{
          "billed_charge": 385.00,
          "npi": [1215460944]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "97110",
    "description": "THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "474155013"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 50.90,
        "providers": [{
          "billed_charge": 500.00,
          "npi": []
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "134085568"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 40.51,
        "providers": [{
          "billed_charge": 75.00,
          "npi": [1639425143]
        },{
          "billed_charge": 150.00,
          "npi": [1639425143]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "262567479"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 40.51,
        "providers": [{
          "billed_charge": 150.00,
          "npi": [1134457344]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "270242223"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 31.93,
        "providers": [{
          "billed_charge": 100.00,
          "npi": [1013384734,1144801655]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "824159533"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 48.99,
        "providers": [{
          "billed_charge": 200.00,
          "npi": [1952540536]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "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": "270242223"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 35.52,
        "providers": [{
          "billed_charge": 100.00,
          "npi": [1013384734]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "134085568"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 45.03,
        "providers": [{
          "billed_charge": 75.00,
          "npi": [1639425143]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "853751614"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 34.85,
        "providers": [{
          "billed_charge": 150.00,
          "npi": [1154355766]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "97140",
    "description": "MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "853769709"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 29.55,
        "providers": [{
          "billed_charge": 300.00,
          "npi": [1033799440,1225878861,1285248971,1356807564]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "270242223"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 30.12,
        "providers": [{
          "billed_charge": 100.00,
          "npi": [1013384734,1144801655]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "262567479"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 38.21,
        "providers": [{
          "billed_charge": 150.00,
          "npi": [1134457344]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "474155013"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 46.78,
        "providers": [{
          "billed_charge": 280.00,
          "npi": []
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "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": "134085568"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 49.18,
        "providers": [{
          "billed_charge": 75.00,
          "npi": [1639425143]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "853751614"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 38.06,
        "providers": [{
          "billed_charge": 150.00,
          "npi": [1154355766]
        }]
      }]
    },{
      "tin": {
        "type": "ein",
        "value": "270242223"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 38.74,
        "providers": [{
          "billed_charge": 200.00,
          "npi": [1013384734,1144801655]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "98940",
    "description": "CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, 1-2 REGIONS",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "471739640"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 37.09,
        "providers": [{
          "billed_charge": 125.00,
          "npi": [1134213309]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "CPT",
    "billing_code_type_version": "CPT 2026",
    "billing_code": "99233",
    "description": "SUBSEQUENT HOSPITAL INPATIENT OR OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES A MEDICALLY APPROPRIATE HISTORY AND/OR EXAMINATION AND HIGH LEVEL OF MEDICAL DECISION MAKING. WHEN USING TOTAL TIME ON THE DATE OF THE ENCOUNTER FOR CODE SELECTION, 50 MINUTES MUST BE MET OR EXCEEDED.",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "300537029"
      },
      "service_code": ["21"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 113.96,
        "providers": [{
          "billed_charge": 500.00,
          "npi": [1275112138,1508446014,1528646015,1710783261,1861020760]
        }]
      }]
    }]
  },{
    "name": "Established Patient Office or Other Outpatient Services",
    "billing_code_type": "HCPCS",
    "billing_code_type_version": "HCPCS 2026 Q1",
    "billing_code": "G0283",
    "description": "Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care",
    "allowed_amounts": [{
      "tin": {
        "type": "ein",
        "value": "824159533"
      },
      "service_code": ["11"],
      "billing_class": "PROFESSIONAL",
      "payments": [{
        "allowed_amount": 21.10,
        "providers": [{
          "billed_charge": 200.00,
          "npi": [1952540536]
        }]
      }]
    }]
  }]
}
