{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-08-25", "version": "2.1.0", "out_of_network": [{"name": "PSYCHOTHERAPY W/PATIENT 60 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "90837", "description": "PSYCHOTHERAPY W/PATIENT 60 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "01-0319802"}, "service_code": ["10"], "billing_class": "professional", "billing_code_modifier": ["95"], "payments": [{"allowed_amount": 97.78, "providers": [{"billed_charge": 205, "npi": [0]}]}]}]}, {"name": "SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99233", "description": "SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "22-2519596"}, "service_code": ["21"], "billing_class": "professional", "payments": [{"allowed_amount": 106.46, "providers": [{"billed_charge": 783, "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": "22-2519596"}, "service_code": ["21"], "billing_class": "professional", "payments": [{"allowed_amount": 70.14, "providers": [{"billed_charge": 525, "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": 43.63, "providers": [{"billed_charge": 47.76, "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": 461.77, "providers": [{"billed_charge": 463.89, "npi": [0]}]}]}]}]}