{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-05-29", "version": "1.0.0", "out_of_network": [{"name": "ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "97153", "description": "ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "81-4740830"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 327.11, "providers": [{"billed_charge": 526.88, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "86-3661185"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 1131.44, "providers": [{"billed_charge": 8803.93, "npi": [0]}]}]}]}, {"name": "ALL INCLUSIVE ANCILLARY", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "0240", "description": "ALL INCLUSIVE ANCILLARY", "allowed_amounts": [{"tin": {"type": "ein", "value": "71-0236856"}, "service_code": ["62"], "billing_class": "institutional", "payments": [{"allowed_amount": 694.34, "providers": [{"billed_charge": 1250.07, "npi": [0]}]}]}]}, {"name": "APPL MODALITY 1/> AREAS ELEC STIMJ UNATTENDED", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "97014", "description": "APPL MODALITY 1/> AREAS ELEC STIMJ UNATTENDED", "allowed_amounts": [{"tin": {"type": "ein", "value": "46-1497713"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 10, "npi": [0]}]}]}]}, {"name": "CHIROPRACTIC MANIPLTV TX EXTRASPINAL 1/> REGION", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "98943", "description": "CHIROPRACTIC MANIPLTV TX EXTRASPINAL 1/> REGION", "allowed_amounts": [{"tin": {"type": "ein", "value": "46-1497713"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 27, "npi": [0]}]}]}]}, {"name": "CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "98941", "description": "CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS", "allowed_amounts": [{"tin": {"type": "ein", "value": "46-1497713"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 17.99, "providers": [{"billed_charge": 55, "npi": [0]}]}]}]}, {"name": "GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "82947", "description": "GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP", "allowed_amounts": [{"tin": {"type": "ein", "value": "71-0410253"}, "service_code": ["81"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 15.71, "npi": [0]}]}]}]}, {"name": "LABORATORY - CLINICAL DIAGNOSTIC: CHEMISTRY", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "0301", "description": "LABORATORY - CLINICAL DIAGNOSTIC: CHEMISTRY", "allowed_amounts": [{"tin": {"type": "ein", "value": "71-0236856"}, "service_code": ["62"], "billing_class": "institutional", "payments": [{"allowed_amount": 8.76, "providers": [{"billed_charge": 91.36, "npi": [0]}]}]}]}, {"name": "OTHER HOME HEALTH VISIT", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "0589", "description": "OTHER HOME HEALTH VISIT", "allowed_amounts": [{"tin": {"type": "ein", "value": "62-1656610"}, "service_code": ["12"], "billing_class": "institutional", "payments": [{"allowed_amount": 636.75, "providers": [{"billed_charge": 849, "npi": [0]}]}]}]}, {"name": "PRIVATE DUTY/INDEPENDENT NSG", "billing_code_type": "HCPCS", "billing_code_type_version": "1.0.0", "billing_code": "T1000", "description": "PRIVATE DUTY/INDEPENDENT NSG", "allowed_amounts": [{"tin": {"type": "ein", "value": "62-1656610"}, "service_code": ["12"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 849, "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": 1877.15, "providers": [{"billed_charge": 1877.15, "npi": [0]}]}]}]}, {"name": "VISIT CHARGE", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "0551", "description": "VISIT CHARGE", "allowed_amounts": [{"tin": {"type": "ein", "value": "71-0236856"}, "service_code": ["12"], "billing_class": "institutional", "payments": [{"allowed_amount": 292.56, "providers": [{"billed_charge": 343, "npi": [0]}]}]}]}]}