{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-09-29", "version": "2.1.0", "out_of_network": [{"name": "ALL INCLUSIVE ANCILLARY", "billing_code_type": "RC", "billing_code_type_version": "2.1.0", "billing_code": "0240", "description": "ALL INCLUSIVE ANCILLARY", "allowed_amounts": [{"tin": {"type": "ein", "value": "85-3777599"}, "service_code": ["22"], "billing_class": "institutional", "payments": [{"allowed_amount": 4790.43, "providers": [{"billed_charge": 22237.94, "npi": [0]}]}]}]}, {"name": "ASSAY OF MAGNESIUM", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "83735", "description": "ASSAY OF MAGNESIUM", "allowed_amounts": [{"tin": {"type": "ein", "value": "57-1122647"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 13.08, "npi": [0]}]}]}]}, {"name": "BASIC METABOLIC PANEL CALCIUM TOTAL", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "80048", "description": "BASIC METABOLIC PANEL CALCIUM TOTAL", "allowed_amounts": [{"tin": {"type": "ein", "value": "57-1122647"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 14.34, "npi": [0]}]}]}]}, {"name": "BLOOD COUNT COMPLETE AUTOMATED", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "85027", "description": "BLOOD COUNT COMPLETE AUTOMATED", "allowed_amounts": [{"tin": {"type": "ein", "value": "57-1122647"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 10.97, "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": 25.14, "providers": [{"billed_charge": 26.58, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 216.99, "providers": [{"billed_charge": 216.99, "npi": [0]}]}]}]}, {"name": "THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97112", "description": "THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA", "allowed_amounts": [{"tin": {"type": "ein", "value": "72-1481972"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 29.96, "providers": [{"billed_charge": 72, "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": "72-1481972"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 35.03, "providers": [{"billed_charge": 117.82, "npi": [0]}]}]}]}, {"name": "THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "85730", "description": "THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD", "allowed_amounts": [{"tin": {"type": "ein", "value": "57-1122647"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 22.5, "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": 1610.17, "providers": [{"billed_charge": 1675.07, "npi": [0]}]}]}]}]}