{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-04-23", "version": "1.0.0", "out_of_network": [{"name": "ASSAY OF MAGNESIUM", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "83735", "description": "ASSAY OF MAGNESIUM", "allowed_amounts": [{"tin": {"type": "ein", "value": "37-1520288"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 20.45, "npi": [0]}]}]}]}, {"name": "BASIC METABOLIC PANEL CALCIUM TOTAL", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "80048", "description": "BASIC METABOLIC PANEL CALCIUM TOTAL", "allowed_amounts": [{"tin": {"type": "ein", "value": "37-1520288"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 76.2, "npi": [0]}]}]}]}, {"name": "BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "85025", "description": "BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC", "allowed_amounts": [{"tin": {"type": "ein", "value": "37-1520288"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 21.14, "npi": [0]}]}]}]}, {"name": "GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "82805", "description": "GASES BLOOD PH DIRECT MEAS XCPT PULSE OXIMITRY", "allowed_amounts": [{"tin": {"type": "ein", "value": "37-1520288"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 55.73, "npi": [0]}]}]}]}, {"name": "HEPATIC FUNCTION PANEL", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "80076", "description": "HEPATIC FUNCTION PANEL", "allowed_amounts": [{"tin": {"type": "ein", "value": "37-1520288"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 70.75, "npi": [0]}]}]}]}, {"name": "RADIOLOGIC EXAM CHEST SINGLE VIEW", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "71045", "description": "RADIOLOGIC EXAM CHEST SINGLE VIEW", "allowed_amounts": [{"tin": {"type": "ein", "value": "74-1688740"}, "service_code": ["21"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 11.22, "providers": [{"billed_charge": 67, "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": "27-1535521"}, "service_code": ["99"], "billing_class": "professional", "payments": [{"allowed_amount": 15.44, "providers": [{"billed_charge": 15.53, "npi": [0]}]}]}]}]}