{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-07-27", "version": "2.1.0", "out_of_network": [{"name": "PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "95117", "description": "PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS", "allowed_amounts": [{"tin": {"type": "ein", "value": "84-0603216"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 20.23, "providers": [{"billed_charge": 44, "npi": [0]}]}]}]}, {"name": "PROLONGED OUTPATIENT E/M SERVICE EACH 15 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99417", "description": "PROLONGED OUTPATIENT E/M SERVICE EACH 15 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "45-2758556"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 6.51, "providers": [{"billed_charge": 400, "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": 21.87, "providers": [{"billed_charge": 23.9, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "63-1157085"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 2315.81, "providers": [{"billed_charge": 4539.44, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11", "99"], "billing_class": "professional", "payments": [{"allowed_amount": 158.08, "providers": [{"billed_charge": 158.08, "npi": [0]}]}, {"allowed_amount": 250.07, "providers": [{"billed_charge": 250.07, "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": 1203.98, "providers": [{"billed_charge": 1277.39, "npi": [0]}]}]}]}]}