{"reporting_entity_name": "Imagine360", "reporting_entity_type": "Third party administrator", "last_updated_on": "2026-07-27", "version": "2.1.0", "out_of_network": [{"name": "COLLJ VEN BLD VNPNXR", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "36415", "description": "COLLJ VEN BLD VNPNXR", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 13.05, "providers": [{"billed_charge": 27, "npi": [0]}]}]}]}, {"name": "Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "77387", "description": "Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed", "allowed_amounts": [{"tin": {"type": "ein", "value": "541922084"}, "service_code": ["22"], "billing_class": "professional", "billing_code_modifier": ["26"], "payments": [{"allowed_amount": 55.65, "providers": [{"billed_charge": 289.88, "npi": [0]}]}]}]}, {"name": "MEDICATION LIST DOCD IN MEDICAL RECORD", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "1159F", "description": "MEDICATION LIST DOCD IN MEDICAL RECORD", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT DIASTOLIC BLOOD PRESSURE < 80 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3078F", "description": "MOST RECENT DIASTOLIC BLOOD PRESSURE < 80 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT DIASTOLIC BLOOD PRESSURE 80-89 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3079F", "description": "MOST RECENT DIASTOLIC BLOOD PRESSURE 80-89 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT SYSTOLIC BLOOD PRESSURE <130 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3074F", "description": "MOST RECENT SYSTOLIC BLOOD PRESSURE <130 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "MOST RECENT SYSTOLIC BLOOD PRESSURE >= 140 MM HG", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "3077F", "description": "MOST RECENT SYSTOLIC BLOOD PRESSURE >= 140 MM HG", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 0, "providers": [{"billed_charge": 0, "npi": [0]}]}]}]}, {"name": "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter...", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99213", "description": "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter...", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 98.34, "providers": [{"billed_charge": 164.57, "npi": [0]}]}]}]}, {"name": "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the enco...", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "99214", "description": "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the enco...", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 146.1, "providers": [{"billed_charge": 229.57, "npi": [0]}]}]}]}, {"name": "Psychotherapy, 60 minutes with patient", "billing_code_type": "CPT", "billing_code_type_version": "2.1.0", "billing_code": "90837", "description": "Psychotherapy, 60 minutes with patient", "allowed_amounts": [{"tin": {"type": "ein", "value": "994192416"}, "service_code": ["02"], "billing_class": "professional", "payments": [{"allowed_amount": 148.76, "providers": [{"billed_charge": 310, "npi": [0]}]}]}]}, {"name": "Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patie...", "billing_code_type": "HCPCS", "billing_code_type_version": "2.1.0", "billing_code": "G2211", "description": "Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patie...", "allowed_amounts": [{"tin": {"type": "ein", "value": "541586601"}, "service_code": ["11"], "billing_class": "professional", "payments": [{"allowed_amount": 22.63, "providers": [{"billed_charge": 50, "npi": [0]}]}]}]}]}