{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-10-29", "version": "2.1.0", "out_of_network": [{"name": "ALCOHOL AND/OR DRUG SERVICES", "billing_code_type": "HCPCS", "billing_code_type_version": "2.1.0", "billing_code": "H0020", "description": "ALCOHOL AND/OR DRUG SERVICES", "allowed_amounts": [{"tin": {"type": "ein", "value": "06-0646665"}, "service_code": ["57"], "billing_class": "professional", "payments": [{"allowed_amount": 21.68, "providers": [{"billed_charge": 74.99, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "86-2039947"}, "service_code": ["58", "22"], "billing_class": "professional", "payments": [{"allowed_amount": 8.61, "providers": [{"billed_charge": 39.28, "npi": [0]}]}, {"allowed_amount": 12, "providers": [{"billed_charge": 81.41, "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": 21.9, "providers": [{"billed_charge": 22, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "47-4999303"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 437.12, "providers": [{"billed_charge": 470.67, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "75-1617587"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 92.5, "providers": [{"billed_charge": 92.5, "npi": [0]}]}]}]}, {"name": "TAKE-HOME METH", "billing_code_type": "HCPCS", "billing_code_type_version": "2.1.0", "billing_code": "G2078", "description": "TAKE-HOME METH", "allowed_amounts": [{"tin": {"type": "ein", "value": "86-2039947"}, "service_code": ["22"], "billing_class": "professional", "payments": [{"allowed_amount": 38.53, "providers": [{"billed_charge": 85, "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": 426.1, "providers": [{"billed_charge": 590.21, "npi": [0]}]}]}]}]}