{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-10-29", "version": "2.1.0", "out_of_network": [{"name": "APPL MODALITY 1/> AREAS ELEC STIMJ UNATTENDED", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97014", "description": "APPL MODALITY 1/> AREAS ELEC STIMJ UNATTENDED", "allowed_amounts": [{"tin": {"type": "ein", "value": "14-1923476"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["59"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 45, "npi": [0]}]}]}]}, {"name": "APPL MODALITY 1/> AREAS TRACTION MECHANICAL", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97012", "description": "APPL MODALITY 1/> AREAS TRACTION MECHANICAL", "allowed_amounts": [{"tin": {"type": "ein", "value": "14-1923476"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["59"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 45, "npi": [0]}]}]}]}, {"name": "CHIROPRACTIC MANIPULATIVE TX SPINAL 1-2 REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "98940", "description": "CHIROPRACTIC MANIPULATIVE TX SPINAL 1-2 REGIONS", "allowed_amounts": [{"tin": {"type": "ein", "value": "14-1923476"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 25.38, "providers": [{"billed_charge": 50, "npi": [0]}]}]}]}, {"name": "PSYCHOTHERAPY W/PATIENT 60 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "90837", "description": "PSYCHOTHERAPY W/PATIENT 60 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "30-0472037"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 136.07, "providers": [{"billed_charge": 300, "npi": [0]}]}]}]}, {"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": 18.42, "providers": [{"billed_charge": 18.71, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 156, "providers": [{"billed_charge": 156, "npi": [0]}]}]}]}, {"name": "THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97110", "description": "THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES", "allowed_amounts": [{"tin": {"type": "ein", "value": "14-1923476"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["59"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 45, "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": 617.78, "providers": [{"billed_charge": 647.34, "npi": [0]}]}]}]}]}