{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-08-25", "version": "2.1.0", "out_of_network": [{"name": "CEFEPIME HCL FOR INJECTION", "billing_code_type": "HCPCS", "billing_code_type_version": "2.1.0", "billing_code": "J0692", "description": "CEFEPIME HCL FOR INJECTION", "allowed_amounts": [{"tin": {"type": "ein", "value": "58-2379261"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["JZ"], "payments": [{"allowed_amount": 12.14, "providers": [{"billed_charge": 540, "npi": [0]}]}]}]}, {"name": "DRUGS UNCLASSIFIED INJECTION", "billing_code_type": "HCPCS", "billing_code_type_version": "2.1.0", "billing_code": "J3490", "description": "DRUGS UNCLASSIFIED INJECTION", "allowed_amounts": [{"tin": {"type": "ein", "value": "58-2379261"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["JZ"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 1975.81, "npi": [0]}, {"billed_charge": 1988.64, "npi": [0]}]}]}]}, {"name": "MEROPENEM", "billing_code_type": "HCPCS", "billing_code_type_version": "2.1.0", "billing_code": "J2185", "description": "MEROPENEM", "allowed_amounts": [{"tin": {"type": "ein", "value": "58-2379261"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["JZ"], "payments": [{"allowed_amount": 15.09, "providers": [{"billed_charge": 934, "npi": [0]}]}, {"allowed_amount": 17.4, "providers": [{"billed_charge": 945.45, "npi": [0]}]}]}]}, {"name": "OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99202", "description": "OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "47-1421985"}, "service_code": ["02"], "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": 57.89, "providers": [{"billed_charge": 85.14, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 204.85, "providers": [{"billed_charge": 204.85, "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": 731.87, "providers": [{"billed_charge": 731.87, "npi": [0]}]}]}]}]}