{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-06-26", "version": "1.0.0", "out_of_network": [{"name": "CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "98941", "description": "CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2741886"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 37.62, "providers": [{"billed_charge": 60, "npi": [0]}]}]}]}, {"name": "MOST RECENT DIASTOLIC BLOOD PRESSURE < 80 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "3078F", "description": "MOST RECENT DIASTOLIC BLOOD PRESSURE < 80 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2616977"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "npi": [0]}]}]}]}, {"name": "MOST RECENT DIASTOLIC BLOOD PRESSURE 80-89 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "3079F", "description": "MOST RECENT DIASTOLIC BLOOD PRESSURE 80-89 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2616977"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "npi": [0]}]}]}]}, {"name": "MOST RECENT SYSTOLIC BLOOD PRES>= 140 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "3077F", "description": "MOST RECENT SYSTOLIC BLOOD PRES>= 140 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2616977"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "npi": [0]}]}]}]}, {"name": "MOST RECENT SYSTOLIC BLOOD PRESS 130-139MM HG", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "3075F", "description": "MOST RECENT SYSTOLIC BLOOD PRESS 130-139MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2616977"}, "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": "1.0.0", "billing_code": "3074F", "description": "MOST RECENT SYSTOLIC BLOOD PRESSURE <130 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2616977"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "npi": [0]}]}]}]}, {"name": "SCR DEP NEG, NO PLAN REQD", "billing_code_type": "HCPCS", "billing_code_type_version": "1.0.0", "billing_code": "G8510", "description": "SCR DEP NEG, NO PLAN REQD", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2616977"}, "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": "1.0.0", "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": 85.98, "providers": [{"billed_charge": 86.05, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "43-1420563"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 6240.5, "providers": [{"billed_charge": 6240.5, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 186.21, "providers": [{"billed_charge": 186.21, "npi": [0]}]}]}]}, {"name": "THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "97110", "description": "THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2741886"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["59"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 45, "npi": [0]}]}]}]}, {"name": "TOTAL CHARGE", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "0001", "description": "TOTAL CHARGE", "allowed_amounts": [{"tin": {"type": "ein", "value": "27-1535521"}, "service_code": ["99"], "billing_class": "institutional", "payments": [{"allowed_amount": 982.1, "providers": [{"billed_charge": 1200.92, "npi": [0]}]}]}]}]}