{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-04-23", "version": "1.0.0", "out_of_network": [{"name": "DETERMINATION REFRACTIVE STATE", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "92015", "description": "DETERMINATION REFRACTIVE STATE", "allowed_amounts": [{"tin": {"type": "ein", "value": "35-1553919"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 31.78, "providers": [{"billed_charge": 39, "npi": [0]}]}]}]}, {"name": "GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "97154", "description": "GROUP ADAPTIVE BHV TX BY PROTOCOL TECH EA 15 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "46-4885502"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 393.24, "providers": [{"billed_charge": 393.24, "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": "26-0502364"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 5483.9, "providers": [{"billed_charge": 5483.9, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "27-1535521"}, "service_code": ["99"], "billing_class": "professional", "payments": [{"allowed_amount": 12.27, "providers": [{"billed_charge": 20.24, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 250.04, "providers": [{"billed_charge": 250.04, "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": 490.45, "providers": [{"billed_charge": 603.81, "npi": [0]}]}]}]}]}