{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-10-29", "version": "2.1.0", "out_of_network": [{"name": "GROUP PSYCHOTHERAPY", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "90853", "description": "GROUP PSYCHOTHERAPY", "allowed_amounts": [{"tin": {"type": "ein", "value": "58-2325982"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 50, "providers": [{"billed_charge": 50, "npi": [0]}]}]}]}, {"name": "MOST RECENT HEMOGLOBIN A1C LEVEL < 7.0%", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3044F", "description": "MOST RECENT HEMOGLOBIN A1C LEVEL < 7.0%", "allowed_amounts": [{"tin": {"type": "ein", "value": "59-0704934"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0.01, "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": "47-4999303"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 7770.86, "providers": [{"billed_charge": 7870.01, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "59-1031071"}, "service_code": ["99"], "billing_class": "professional", "payments": [{"allowed_amount": 117.8, "providers": [{"billed_charge": 117.8, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 86.19, "providers": [{"billed_charge": 86.19, "npi": [0]}]}]}]}]}