{"reporting_entity_name": "GIIC_TPA","reporting_entity_type": "GIIC_TPA","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"name":"Antinuclear antibodies","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86038","description":"Antinuclear antibodies","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":15.53,"providers":[{"billed_charge":107.58,"npi":[1063497451]}]}]}]},{"name":"Assay of free thyroxine","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84439","description":"Assay of free thyroxine","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.59,"providers":[{"billed_charge":80.97,"npi":[1063497451]}]}]}]},{"name":"Assay of insulin","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83525","description":"Assay of insulin","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":14.70,"providers":[{"billed_charge":90.83,"npi":[1063497451]}]}]}]},{"name":"C-reactive protein","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86140","description":"C-reactive protein","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":6.65,"providers":[{"billed_charge":84.00,"npi":[1063497451]},{"billed_charge":86.63,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":9.99,"providers":[{"billed_charge":32.55,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":13.60,"providers":[{"billed_charge":48.30,"npi":[1063497451]}]}]}]},{"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":205.20,"providers":[{"billed_charge":1280.00,"npi":[1932703022]}]}]}]},{"name":"Free assay (ft-3)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84481","description":"Free assay (ft-3)","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":21.77,"providers":[{"billed_charge":232.58,"npi":[1063497451]}]}]}]},{"name":"General health panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80050","description":"General health panel","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.18,"providers":[{"billed_charge":192.68,"npi":[1063497451]},{"billed_charge":231.93,"npi":[1063497451]}]}]}]},{"name":"Glycosylated hemoglobin test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83036","description":"Glycosylated hemoglobin test","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":12.46,"providers":[{"billed_charge":71.93,"npi":[1063497451]}]}]}]},{"name":"Lipid panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80061","description":"Lipid panel","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":16.74,"providers":[{"billed_charge":102.90,"npi":[1063497451]},{"billed_charge":105.53,"npi":[1063497451]}]}]}]},{"name":"Rbc sed rate automated","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85652","description":"Rbc sed rate automated","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":3.47,"providers":[{"billed_charge":37.80,"npi":[1063497451]},{"billed_charge":40.43,"npi":[1063497451]}]}]}]},{"name":"Rheumatoid factor quant","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86431","description":"Rheumatoid factor quant","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":7.28,"providers":[{"billed_charge":50.93,"npi":[1063497451]}]}]}]},{"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]}]}]}]}]}