{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-05-29", "version": "1.0.0", "out_of_network": [{"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": "81-2782346"}, "service_code": ["50"], "billing_class": "institutional", "payments": [{"allowed_amount": 61.52, "providers": [{"billed_charge": 3580, "npi": [0]}]}]}]}, {"name": "EMERGENCY ROOM", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "0450", "description": "EMERGENCY ROOM", "allowed_amounts": [{"tin": {"type": "ein", "value": "35-0867958"}, "service_code": ["23"], "billing_class": "institutional", "payments": [{"allowed_amount": 1424.61, "providers": [{"billed_charge": 16368.39, "npi": [0]}]}]}]}, {"name": "LABORATORY - CLINICAL DIAGNOSTIC", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "0300", "description": "LABORATORY - CLINICAL DIAGNOSTIC", "allowed_amounts": [{"tin": {"type": "ein", "value": "35-0867958"}, "service_code": ["22"], "billing_class": "institutional", "payments": [{"allowed_amount": 108.56, "providers": [{"billed_charge": 455.98, "npi": [0]}]}]}]}, {"name": "OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "99213", "description": "OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "99-2145793"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 94.86, "providers": [{"billed_charge": 127, "npi": [0]}]}]}]}, {"name": "SKILLS TRAIN AND DEV, 15 MIN", "billing_code_type": "HCPCS", "billing_code_type_version": "1.0.0", "billing_code": "H2014", "description": "SKILLS TRAIN AND DEV, 15 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "82-2287119"}, "service_code": ["53"], "billing_class": "professional", "billing_code_modifier": ["HW"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 297.84, "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": "26-0502364"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 3029.79, "providers": [{"billed_charge": 3029.79, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "27-1535521"}, "service_code": ["99"], "billing_class": "professional", "payments": [{"allowed_amount": 33.84, "providers": [{"billed_charge": 34.58, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 317.2, "providers": [{"billed_charge": 317.2, "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": 751.57, "providers": [{"billed_charge": 919.26, "npi": [0]}]}]}]}]}