{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-10-29", "version": "2.1.0", "out_of_network": [{"name": "ALL INCLUSIVE ANCILLARY", "billing_code_type": "RC", "billing_code_type_version": "2.1.0", "billing_code": "0240", "description": "ALL INCLUSIVE ANCILLARY", "allowed_amounts": [{"tin": {"type": "ein", "value": "59-3238634"}, "service_code": ["22"], "billing_class": "institutional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 5207, "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": "59-3238634"}, "service_code": ["22"], "billing_class": "institutional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 309, "npi": [0]}]}]}]}, {"name": "DIABETIC MANAGEMENT PROGRAM,", "billing_code_type": "HCPCS", "billing_code_type_version": "2.1.0", "billing_code": "S9140", "description": "DIABETIC MANAGEMENT PROGRAM,", "allowed_amounts": [{"tin": {"type": "ein", "value": "26-3542036"}, "service_code": ["10"], "billing_class": "professional", "payments": [{"allowed_amount": 75, "providers": [{"billed_charge": 75, "npi": [0]}]}]}]}, {"name": "EMERGENCY ROOM", "billing_code_type": "RC", "billing_code_type_version": "2.1.0", "billing_code": "0450", "description": "EMERGENCY ROOM", "allowed_amounts": [{"tin": {"type": "ein", "value": "99-2646504"}, "service_code": ["23"], "billing_class": "institutional", "payments": [{"allowed_amount": 1029.38, "providers": [{"billed_charge": 10872.8, "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": "PREV MED CNSL&/RSK FCTR RDCTJ INDV APPROX 30 MIN", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99402", "description": "PREV MED CNSL&/RSK FCTR RDCTJ INDV APPROX 30 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "20-1908041"}, "service_code": ["99"], "billing_class": "professional", "payments": [{"allowed_amount": 60.53, "providers": [{"billed_charge": 91.62, "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": 8.26, "providers": [{"billed_charge": 8.27, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 192.75, "providers": [{"billed_charge": 192.75, "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": 1169.87, "providers": [{"billed_charge": 1795.81, "npi": [0]}]}]}]}]}