{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-10-29", "version": "2.1.0", "out_of_network": [{"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": "61-0700826"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "98941", "description": "CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS", "allowed_amounts": [{"tin": {"type": "ein", "value": "84-3980931"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 34.87, "providers": [{"billed_charge": 34.87, "npi": [0]}]}]}]}, {"name": "CLINIC", "billing_code_type": "RC", "billing_code_type_version": "2.1.0", "billing_code": "0510", "description": "CLINIC", "allowed_amounts": [{"tin": {"type": "ein", "value": "61-6001218"}, "service_code": ["22"], "billing_class": "institutional", "payments": [{"allowed_amount": 158.98, "providers": [{"billed_charge": 446.72, "npi": [0]}]}]}]}, {"name": "LABORATORY - CLINICAL DIAGNOSTIC", "billing_code_type": "RC", "billing_code_type_version": "2.1.0", "billing_code": "0300", "description": "LABORATORY - CLINICAL DIAGNOSTIC", "allowed_amounts": [{"tin": {"type": "ein", "value": "61-0444707"}, "service_code": ["22"], "billing_class": "institutional", "payments": [{"allowed_amount": 184.56, "providers": [{"billed_charge": 2111.64, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "61-1286361"}, "service_code": ["22"], "billing_class": "institutional", "payments": [{"allowed_amount": 63.95, "providers": [{"billed_charge": 261.86, "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": "20-3131989"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "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": "20-3131989"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "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": "20-3131989"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "npi": [0]}]}]}]}, {"name": "OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99213", "description": "OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "61-0700826"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 64.9, "providers": [{"billed_charge": 180.73, "npi": [0]}]}]}]}, {"name": "OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99214", "description": "OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "61-0700826"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 106.19, "providers": [{"billed_charge": 253.96, "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": "61-0492356"}, "service_code": ["62"], "billing_class": "institutional", "payments": [{"allowed_amount": 211.96, "providers": [{"billed_charge": 520.35, "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": "20-3131989"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "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": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 221.41, "providers": [{"billed_charge": 221.41, "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": 622.88, "providers": [{"billed_charge": 667.33, "npi": [0]}]}]}]}]}