{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-10-29", "version": "2.1.0", "out_of_network": [{"name": "ACE INHIBITOR/ARB THERAPY RXD/CURRENTLY TAKEN", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "4010F", "description": "ACE INHIBITOR/ARB THERAPY RXD/CURRENTLY TAKEN", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "ADV CARE PLN TLKD & ALT DCSN MAKER DOCD", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "1123F", "description": "ADV CARE PLN TLKD & ALT DCSN MAKER DOCD", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"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": "85-3525556"}, "service_code": ["50"], "billing_class": "institutional", "payments": [{"allowed_amount": 396.89, "providers": [{"billed_charge": 3759, "npi": [0]}]}]}]}, {"name": "BODY MASS INDEX DOCUMENTED", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3008F", "description": "BODY MASS INDEX DOCUMENTED", "allowed_amounts": [{"tin": {"type": "ein", "value": "35-0670330"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "CURRENT TOBACCO NON-USER CAD CAP COPD PV DM", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "1036F", "description": "CURRENT TOBACCO NON-USER CAD CAP COPD PV DM", "allowed_amounts": [{"tin": {"type": "ein", "value": "35-0670330"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99000", "description": "HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB", "allowed_amounts": [{"tin": {"type": "ein", "value": "37-1206525"}, "service_code": ["81"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 21.16, "npi": [0]}]}]}]}, {"name": "MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97140", "description": "MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "92-2284436"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 18.74, "providers": [{"billed_charge": 52.08, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "93-2484289"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 36.56, "providers": [{"billed_charge": 98.69, "npi": [0]}]}]}]}, {"name": "MEDICATION LIST DOCUMENTED IN MEDICAL RECORD", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "1159F", "description": "MEDICATION LIST DOCUMENTED IN MEDICAL RECORD", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT DIASTOL BLOOD PRES >= 90 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3080F", "description": "MOST RECENT DIASTOL BLOOD PRES >= 90 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT DIASTOLIC BLOOD PRESSURE < 80 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3078F", "description": "MOST RECENT DIASTOLIC BLOOD PRESSURE < 80 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "35-0670330"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT DIASTOLIC BLOOD PRESSURE 80-89 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3079F", "description": "MOST RECENT DIASTOLIC BLOOD PRESSURE 80-89 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "35-0670330"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT HEMOGLOBIN A1C LEVEL < 7.0%", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3044F", "description": "MOST RECENT HEMOGLOBIN A1C LEVEL < 7.0%", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT LDL-C <100 MG/DL", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3048F", "description": "MOST RECENT LDL-C <100 MG/DL", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT LDL-C >= 130 MG/DL", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3050F", "description": "MOST RECENT LDL-C >= 130 MG/DL", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT LDL-C 100-129 MG/DL", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3049F", "description": "MOST RECENT LDL-C 100-129 MG/DL", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT SYSTOLIC BLOOD PRES>= 140 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3077F", "description": "MOST RECENT SYSTOLIC BLOOD PRES>= 140 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT SYSTOLIC BLOOD PRESS 130-139MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3075F", "description": "MOST RECENT SYSTOLIC BLOOD PRESS 130-139MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT SYSTOLIC BLOOD PRESSURE <130 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3074F", "description": "MOST RECENT SYSTOLIC BLOOD PRESSURE <130 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "35-0670330"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "POSITIVE MACROALBUMINURIA TEST RESULT DOC&REV", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3062F", "description": "POSITIVE MACROALBUMINURIA TEST RESULT DOC&REV", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "PT FALLS ASSESS DOCD W/O FALL/INJURY PAST YEAR", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "1101F", "description": "PT FALLS ASSESS DOCD W/O FALL/INJURY PAST YEAR", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "RVW ALL MEDS BY RXNG PRCTIONR OR CLIN RPH DOCD", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "1160F", "description": "RVW ALL MEDS BY RXNG PRCTIONR OR CLIN RPH DOCD", "allowed_amounts": [{"tin": {"type": "ein", "value": "36-2657618"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "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": "92-2284436"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 21.87, "providers": [{"billed_charge": 55, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "93-2484289"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 50.94, "providers": [{"billed_charge": 145.76, "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": "92-2284436"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 29.82, "providers": [{"billed_charge": 60, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "93-2484289"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 61.65, "providers": [{"billed_charge": 159.2, "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": "82-3321385"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 52.65, "providers": [{"billed_charge": 210.35, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "92-2284436"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 38.94, "providers": [{"billed_charge": 100, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "93-2484289"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 22.76, "providers": [{"billed_charge": 63.62, "npi": [0]}]}]}]}]}