{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-05-29", "version": "1.0.0", "out_of_network": [{"name": "DOCREV CUR MEDS BY ELIG CLIN", "billing_code_type": "HCPCS", "billing_code_type_version": "1.0.0", "billing_code": "G8427", "description": "DOCREV CUR MEDS BY ELIG CLIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "83-3274998"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "99202", "description": "OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "47-1421985"}, "service_code": ["02"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "PT SCRN TBCO ID AS NON USER", "billing_code_type": "HCPCS", "billing_code_type_version": "1.0.0", "billing_code": "G9903", "description": "PT SCRN TBCO ID AS NON USER", "allowed_amounts": [{"tin": {"type": "ein", "value": "83-3274998"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "99070", "description": "SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP", "allowed_amounts": [{"tin": {"type": "ein", "value": "27-1535521"}, "service_code": ["99"], "billing_class": "professional", "payments": [{"allowed_amount": 36.31, "providers": [{"billed_charge": 39.05, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 150.45, "providers": [{"billed_charge": 150.45, "npi": [0]}]}]}]}, {"name": "TOTAL CHARGE", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "0001", "description": "TOTAL CHARGE", "allowed_amounts": [{"tin": {"type": "ein", "value": "27-1535521"}, "service_code": ["99"], "billing_class": "institutional", "payments": [{"allowed_amount": 1102.6, "providers": [{"billed_charge": 1219.42, "npi": [0]}]}]}]}]}