{"reporting_entity_name": "GIIC_TPA","reporting_entity_type": "GIIC_TPA","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"name":"Assay of magnesium","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83735","description":"Assay of magnesium","allowed_amounts":[{"tin":{"type":"ein","value":"133971298"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":62.00,"npi":[1619341716]}]}]}]},{"name":"Complete cbc w\/auto diff wbc","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85025","description":"Complete cbc w\/auto diff wbc","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":9.99,"providers":[{"billed_charge":32.55,"npi":[1063497451]}]}]}]},{"name":"Complete cbc w\/auto diff wbc","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85025","description":"Complete cbc w\/auto diff wbc","allowed_amounts":[{"tin":{"type":"ein","value":"133971298"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":40.61,"providers":[{"billed_charge":138.61,"npi":[1619341716]}]}]}]},{"name":"Comprehen metabolic panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80053","description":"Comprehen metabolic panel","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":13.60,"providers":[{"billed_charge":48.30,"npi":[1063497451]}]}]}]},{"name":"Comprehen metabolic panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80053","description":"Comprehen metabolic panel","allowed_amounts":[{"tin":{"type":"ein","value":"133971298"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":95.37,"providers":[{"billed_charge":325.51,"npi":[1619341716]}]}]}]},{"name":"Emergency dept visit","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99284","description":"Emergency dept visit","allowed_amounts":[{"tin":{"type":"ein","value":"273953335"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":128.00,"providers":[{"billed_charge":1870.00,"npi":[1366606576]}]},{"allowed_amount":205.20,"providers":[{"billed_charge":1280.00,"npi":[1972579225]}]}]}]},{"name":"Hydrate iv infusion add-on","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96361","description":"Hydrate iv infusion add-on","allowed_amounts":[{"tin":{"type":"ein","value":"133971298"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":296.86,"providers":[{"billed_charge":1013.25,"npi":[1619341716]}]}]}]},{"name":"Normal saline solution infus","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J7050","description":"Normal saline solution infus","allowed_amounts":[{"tin":{"type":"ein","value":"133971298"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":18.46,"providers":[{"billed_charge":63.00,"npi":[1619341716]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":2.75,"providers":[{"billed_charge":26.25,"npi":[1063497451]}]}]}]},{"name":"Ther\/proph\/diag inj iv push","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96374","description":"Ther\/proph\/diag inj iv push","allowed_amounts":[{"tin":{"type":"ein","value":"133971298"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":393.54,"providers":[{"billed_charge":1343.23,"npi":[1619341716]}]}]}]},{"name":"Urine pregnancy test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81025","description":"Urine pregnancy test","allowed_amounts":[{"tin":{"type":"ein","value":"133971298"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":13.46,"providers":[{"billed_charge":45.93,"npi":[1619341716]}]}]}]}]}