{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-09-29", "version": "2.1.0", "out_of_network": [{"name": "CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99291", "description": "CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "27-2374581"}, "service_code": ["21"], "billing_class": "professional", "payments": [{"allowed_amount": 416, "providers": [{"billed_charge": 416, "npi": [0]}]}]}]}, {"name": "MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97140", "description": "MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "86-0861354"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 99.96, "providers": [{"billed_charge": 99.96, "npi": [0]}]}]}]}, {"name": "SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99233", "description": "SBSQ HOSPITAL IP/OBS CARE HIGH MDM 50 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "88-0136773"}, "service_code": ["21"], "billing_class": "professional", "payments": [{"allowed_amount": 339, "providers": [{"billed_charge": 339, "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": "77-0183906"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 114.36, "providers": [{"billed_charge": 114.36, "npi": [0]}]}]}]}, {"name": "THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "97110", "description": "THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES", "allowed_amounts": [{"tin": {"type": "ein", "value": "86-0861354"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 70.07, "providers": [{"billed_charge": 70.07, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "91-0858192"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 134.78, "providers": [{"billed_charge": 134.78, "npi": [0]}]}]}]}]}