{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-10-29", "version": "2.1.0", "out_of_network": [{"name": "SCREENING FOR DEPRESSION PERFORMED", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3725F", "description": "SCREENING FOR DEPRESSION PERFORMED", "allowed_amounts": [{"tin": {"type": "ein", "value": "75-2536818"}, "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": "06-1621470"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 30.51, "providers": [{"billed_charge": 30.51, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "27-1535521"}, "service_code": ["99"], "billing_class": "professional", "payments": [{"allowed_amount": 20.06, "providers": [{"billed_charge": 20.3, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 168.14, "providers": [{"billed_charge": 168.14, "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": 812.17, "providers": [{"billed_charge": 852.83, "npi": [0]}]}]}]}]}