{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-08-25", "version": "2.1.0", "out_of_network": [{"name": "EMERGENCY ROOM", "billing_code_type": "RC", "billing_code_type_version": "2.1.0", "billing_code": "0450", "description": "EMERGENCY ROOM", "allowed_amounts": [{"tin": {"type": "ein", "value": "74-2781812"}, "service_code": ["23"], "billing_class": "institutional", "payments": [{"allowed_amount": 1783.72, "providers": [{"billed_charge": 10510.83, "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": "55-0853118"}, "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": "74-2109824"}, "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": "74-2109824"}, "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": "74-2109824"}, "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": "74-2109824"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "PHYSICAL THERAPY", "billing_code_type": "RC", "billing_code_type_version": "2.1.0", "billing_code": "0420", "description": "PHYSICAL THERAPY", "allowed_amounts": [{"tin": {"type": "ein", "value": "27-2266477"}, "service_code": ["12"], "billing_class": "institutional", "payments": [{"allowed_amount": 509.29, "providers": [{"billed_charge": 984.55, "npi": [0]}]}]}]}, {"name": "SBSQ HOSPITAL IP/OBS CARE MOD MDM 35 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99232", "description": "SBSQ HOSPITAL IP/OBS CARE MOD MDM 35 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "47-3553486"}, "service_code": ["21"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 307, "npi": [0]}]}]}]}, {"name": "SCR DEP NEG, NO PLAN REQD", "billing_code_type": "HCPCS", "billing_code_type_version": "2.1.0", "billing_code": "G8510", "description": "SCR DEP NEG, NO PLAN REQD", "allowed_amounts": [{"tin": {"type": "ein", "value": "74-2109824"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "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": 21.98, "providers": [{"billed_charge": 26.79, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 247.59, "providers": [{"billed_charge": 247.59, "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": 1274.41, "providers": [{"billed_charge": 1278.93, "npi": [0]}]}]}]}]}