{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-10-29", "version": "2.1.0", "out_of_network": [{"name": "ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97153", "description": "ADAPTIVE BEHAVIOR TX BY PROTOCOL TECH EA 15 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "86-2444798"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 508.51, "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": "PSYCHOTHERAPY W/PATIENT 45 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "90834", "description": "PSYCHOTHERAPY W/PATIENT 45 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "47-1421985"}, "service_code": ["02"], "billing_class": "professional", "payments": [{"allowed_amount": 85, "providers": [{"billed_charge": 85, "npi": [0]}]}]}]}, {"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": "82-2234905"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 165.74, "providers": [{"billed_charge": 165.74, "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": 47.39, "providers": [{"billed_charge": 48.82, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 161.08, "providers": [{"billed_charge": 161.08, "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": 558.6, "providers": [{"billed_charge": 626.61, "npi": [0]}]}]}]}]}