{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-05-29", "version": "1.0.0", "out_of_network": [{"name": "BEHAVIORAL HEALTH OUTREACH SERVICE (PLANNED APPROACH TO REACH A TARGETED", "billing_code_type": "HCPCS", "billing_code_type_version": "1.0.0", "billing_code": "H0023", "description": "BEHAVIORAL HEALTH OUTREACH SERVICE (PLANNED APPROACH TO REACH A TARGETED", "allowed_amounts": [{"tin": {"type": "ein", "value": "920038588"}, "service_code": ["53"], "billing_class": "professional", "billing_code_modifier": ["V2"], "payments": [{"allowed_amount": 45.94, "providers": [{"billed_charge": 82.03, "npi": [0]}]}]}]}, {"name": "BEHAVIORAL HEALTH; RESIDENTIAL (HOSPITAL RESIDENTIAL TREATMENT PROGRAM),", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "1001", "description": "BEHAVIORAL HEALTH; RESIDENTIAL (HOSPITAL RESIDENTIAL TREATMENT PROGRAM),", "allowed_amounts": [{"tin": {"type": "ein", "value": "261948235"}, "billing_class": "institutional", "payments": [{"allowed_amount": 5047.63, "providers": [{"billed_charge": 5047.63, "npi": [0]}]}]}]}, {"name": "BEHAVIORAL HEALTH; SHORT-TERM RESIDENTIAL (NON-HOSPITAL RESIDENTIAL TREATMENT", "billing_code_type": "RC", "billing_code_type_version": "1.0.0", "billing_code": "1002", "description": "BEHAVIORAL HEALTH; SHORT-TERM RESIDENTIAL (NON-HOSPITAL RESIDENTIAL TREATMENT", "allowed_amounts": [{"tin": {"type": "ein", "value": "822843517"}, "billing_class": "institutional", "payments": [{"allowed_amount": 7940.77, "providers": [{"billed_charge": 7940.77, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "861655892"}, "billing_class": "institutional", "payments": [{"allowed_amount": 5245, "providers": [{"billed_charge": 5245, "npi": [0]}]}]}]}, {"name": "COMMUNITY-BASED WRAP-AROUND SERVICES, PER 15 MINUTES", "billing_code_type": "HCPCS", "billing_code_type_version": "1.0.0", "billing_code": "H2021", "description": "COMMUNITY-BASED WRAP-AROUND SERVICES, PER 15 MINUTES", "allowed_amounts": [{"tin": {"type": "ein", "value": "832233177"}, "service_code": ["53"], "billing_class": "professional", "billing_code_modifier": ["V2"], "payments": [{"allowed_amount": 226.43, "providers": [{"billed_charge": 360.28, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "920086076"}, "service_code": ["53"], "billing_class": "professional", "billing_code_modifier": ["HQ"], "payments": [{"allowed_amount": 30.36, "providers": [{"billed_charge": 35.82, "npi": [0]}]}]}]}, {"name": "MNL THER TQS 1+ REGIONS EA 15 MIN", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "97140", "description": "MNL THER TQS 1+ REGIONS EA 15 MIN", "allowed_amounts": [{"tin": {"type": "ein", "value": "472352897"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["59"], "payments": [{"allowed_amount": 318.97, "providers": [{"billed_charge": 318.97, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "843382747"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 400, "providers": [{"billed_charge": 400, "npi": [0]}]}]}]}, {"name": "OSTEOPATHIC MANIPULATIVE TX 3-4 BDY REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "98926", "description": "OSTEOPATHIC MANIPULATIVE TX 3-4 BDY REGIONS", "allowed_amounts": [{"tin": {"type": "ein", "value": "510658550"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 233.17, "providers": [{"billed_charge": 233.17, "npi": [0]}]}]}]}, {"name": "OSTEOPATHIC MANIPULATIVE TX 5-6 BDY REGIONS", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "98927", "description": "OSTEOPATHIC MANIPULATIVE TX 5-6 BDY REGIONS", "allowed_amounts": [{"tin": {"type": "ein", "value": "472352897"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 177, "providers": [{"billed_charge": 177, "npi": [0]}]}]}]}, {"name": "Psychotherapy, 60 minutes with patient", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "90837", "description": "Psychotherapy, 60 minutes with patient", "allowed_amounts": [{"tin": {"type": "ein", "value": "263025853"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 300, "providers": [{"billed_charge": 300, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "271150529"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 225, "providers": [{"billed_charge": 225, "npi": [0]}]}]}, {"tin": {"type": "ein", "value": "920161193"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 223.43, "providers": [{"billed_charge": 229.69, "npi": [0]}]}]}]}, {"name": "THER PX 1+ AREAS EA 15 MIN MASSAGE", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "97124", "description": "THER PX 1+ AREAS EA 15 MIN MASSAGE", "allowed_amounts": [{"tin": {"type": "ein", "value": "932684901"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GP"], "payments": [{"allowed_amount": 295.68, "providers": [{"billed_charge": 313.54, "npi": [0]}]}]}]}, {"name": "Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "97530", "description": "Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes", "allowed_amounts": [{"tin": {"type": "ein", "value": "510658550"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["59"], "payments": [{"allowed_amount": 333.58, "providers": [{"billed_charge": 333.58, "npi": [0]}]}]}]}, {"name": "THERAPEUTIC BEHAVIORAL SERVICES, PER DIEM", "billing_code_type": "HCPCS", "billing_code_type_version": "1.0.0", "billing_code": "H2020", "description": "THERAPEUTIC BEHAVIORAL SERVICES, PER DIEM", "allowed_amounts": [{"tin": {"type": "ein", "value": "920038588"}, "service_code": ["12"], "billing_class": "professional", "billing_code_modifier": ["V2"], "payments": [{"allowed_amount": 234.97, "providers": [{"billed_charge": 350, "npi": [0]}]}]}]}, {"name": "TX SP LANG COMUNICAJ PCX DISORDER INDIV", "billing_code_type": "CPT", "billing_code_type_version": "1.0.0", "billing_code": "92507", "description": "TX SP LANG COMUNICAJ PCX DISORDER INDIV", "allowed_amounts": [{"tin": {"type": "ein", "value": "274625596"}, "service_code": ["11"], "billing_class": "professional", "billing_code_modifier": ["GN"], "payments": [{"allowed_amount": 200, "providers": [{"billed_charge": 200, "npi": [0]}]}]}]}]}