{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-08-25", "version": "2.1.0", "out_of_network": [{"name": "SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "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": 31.57, "providers": [{"billed_charge": 33.02, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 126.73, "providers": [{"billed_charge": 126.73, "npi": [0]}]}]}]}, {"name": "THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97530", "description": "THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "93-3617011"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GO"], "payments": [{"allowed_amount": 51.33, "providers": [{"billed_charge": 397.06, "npi": [0]}]}]}]}, {"name": "TOTAL CHARGE", "billing_code_type": "RC", "billing_code_type_version": "2.1.0", "billing_code": "0001", "description": "TOTAL CHARGE", "allowed_amounts": [{"tin": {"type": "ein", "value": "27-1535521"}, "service_code": ["99"], "billing_class": "institutional", "payments": [{"allowed_amount": 700.45, "providers": [{"billed_charge": 709.3, "npi": [0]}]}]}]}]}