{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-08-25", "version": "2.1.0", "out_of_network": [{"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": 22.34, "providers": [{"billed_charge": 23.94, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "47-4999303"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 131.44, "providers": [{"billed_charge": 136.94, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 165, "providers": [{"billed_charge": 165, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "87-3756713"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 322.29, "providers": [{"billed_charge": 322.29, "npi": [0]}]}]}]}, {"name": "THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97530", "description": "THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "71-0895055"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GO"], "payments": [{"allowed_amount": 73.1, "providers": [{"billed_charge": 119.48, "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": 880.62, "providers": [{"billed_charge": 884.33, "npi": [0]}]}]}]}]}