{"reporting_entity_name": "GIIC_TPA","reporting_entity_type": "GIIC_TPA","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"name":"Albumin; urine (eg, microalbumin), quantitative","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82043","description":"Albumin; urine (eg, microalbumin), quantitative","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":7.44,"providers":[{"billed_charge":68.20,"npi":[1063497451]},{"billed_charge":71.53,"npi":[1063497451]}]}]}]},{"name":"Ambulance Service Basic Life Support\/Emergency","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0429RH","description":"Ambulance Service Basic Life Support\/Emergency","allowed_amounts":[{"tin":{"type":"ein","value":"246024470"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":432.03,"providers":[{"billed_charge":1050.00,"npi":[1356448765]}]}]}]},{"name":"Ambulance Service Basic Life Support\/Emergency","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0429SH","description":"Ambulance Service Basic Life Support\/Emergency","allowed_amounts":[{"tin":{"type":"ein","value":"232625750"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1100.00,"providers":[{"billed_charge":1100.00,"npi":[1861480949]}]}]}]},{"name":"Ambulance Service Basic Life Support\/Emergency","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0429SH","description":"Ambulance Service Basic Life Support\/Emergency","allowed_amounts":[{"tin":{"type":"ein","value":"232772839"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":432.03,"providers":[{"billed_charge":1000.00,"npi":[1275585655]}]}]}]},{"name":"Ambulance Service Basic Life Support\/Emergency","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0429SH","description":"Ambulance Service Basic Life Support\/Emergency","allowed_amounts":[{"tin":{"type":"ein","value":"237333896"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":600.52,"providers":[{"billed_charge":1100.00,"npi":[1104851427]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427RH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"232832102"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":713.13,"providers":[{"billed_charge":1315.00,"npi":[1578654778]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427SH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"246024144"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1400.00,"providers":[{"billed_charge":1400.00,"npi":[1891854840]}]}]}]},{"name":"Assay of ferritin","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82728","description":"Assay of ferritin","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":17.50,"providers":[{"billed_charge":82.95,"npi":[1063497451]}]}]}]},{"name":"Assay of free testosterone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84402","description":"Assay of free testosterone","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":32.72,"providers":[{"billed_charge":184.48,"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":122.85,"npi":[1063497451]},{"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":88.20,"npi":[1063497451]}]}]}]},{"name":"Assay of iron","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83540","description":"Assay of iron","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.32,"providers":[{"billed_charge":33.08,"npi":[1063497451]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.61,"providers":[{"billed_charge":38.85,"npi":[1063497451]}]}]}]},{"name":"Assay of psa total","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84153","description":"Assay of psa total","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":23.64,"providers":[{"billed_charge":112.35,"npi":[1063497451]}]}]}]},{"name":"Assay of total testosterone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84403","description":"Assay of total testosterone","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":33.19,"providers":[{"billed_charge":187.22,"npi":[1063497451]}]}]}]},{"name":"Assay of urine creatinine","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82570","description":"Assay of urine creatinine","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":6.65,"providers":[{"billed_charge":60.95,"npi":[1063497451]},{"billed_charge":63.92,"npi":[1063497451]}]}]}]},{"name":"Breast Pump, Electric (Acand\/Or Dc,) Any Type","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"E0603NU","description":"Breast Pump, Electric (Acand\/Or Dc,) Any Type","allowed_amounts":[{"tin":{"type":"ein","value":"202536458"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":104.50,"providers":[{"billed_charge":104.50,"npi":[1477222834]}]}]}]},{"name":"Chylmd trach dna amp probe","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87491","description":"Chylmd trach dna amp probe","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.11,"providers":[{"billed_charge":121.72,"npi":[1063497451]}]}]}]},{"name":"Chylmd trach dna amp probe","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87491","description":"Chylmd trach dna amp probe","allowed_amounts":[{"tin":{"type":"ein","value":"621433252"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":38.60,"providers":[{"billed_charge":70.18,"npi":[1689639544]}]}]}]},{"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":"201236503"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":4.12,"providers":[{"billed_charge":31.08,"npi":[1225110497]}]}]}]},{"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":"Cytopath c\/v auto fluid redo","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"88175","description":"Cytopath c\/v auto fluid redo","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":34.05,"providers":[{"billed_charge":114.61,"npi":[1063497451]}]}]}]},{"name":"Disposable collection and storage bag for breast milk, any size, any type, each","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A4287NU","description":"Disposable collection and storage bag for breast milk, any size, any type, each","allowed_amounts":[{"tin":{"type":"ein","value":"202536458"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":92.40,"providers":[{"billed_charge":92.40,"npi":[1477222834]}]}]}]},{"name":"Drug test def 8-14 classes","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0481","description":"Drug test def 8-14 classes","allowed_amounts":[{"tin":{"type":"ein","value":"261565558"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":78.38,"providers":[{"billed_charge":320.00,"npi":[1497933162]}]}]}]},{"name":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT,","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80307","description":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT,","allowed_amounts":[{"tin":{"type":"ein","value":"261565558"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":37.25,"providers":[{"billed_charge":124.00,"npi":[1497933162]}]}]}]},{"name":"Emergency dept visit","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99285","description":"Emergency dept visit","allowed_amounts":[{"tin":{"type":"ein","value":"522103311"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":572.78,"providers":[{"billed_charge":1751.00,"npi":[1073923603]}]}]}]},{"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":190.05,"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":69.30,"npi":[1063497451]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425RH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"232832102"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":139.90,"providers":[{"billed_charge":220.00,"npi":[1578654778]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425RH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"246024470"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":64.05,"providers":[{"billed_charge":140.00,"npi":[1356448765]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425SH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"232625750"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":125.00,"providers":[{"billed_charge":125.00,"npi":[1861480949]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425SH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"232772839"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":118.95,"providers":[{"billed_charge":312.00,"npi":[1275585655]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425SH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"237333896"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":267.09,"providers":[{"billed_charge":556.50,"npi":[1104851427]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425SH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"246024144"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":300.00,"providers":[{"billed_charge":300.00,"npi":[1891854840]}]}]}]},{"name":"Iron binding test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83550","description":"Iron binding test","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.24,"providers":[{"billed_charge":44.62,"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]}]}]}]},{"name":"Med serv 10pm-8am 24 hr fac","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99053","description":"Med serv 10pm-8am 24 hr fac","allowed_amounts":[{"tin":{"type":"ein","value":"522103311"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":51.00,"npi":[1073923603]}]}]}]},{"name":"Metabolic panel total ca","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80048","description":"Metabolic panel total ca","allowed_amounts":[{"tin":{"type":"ein","value":"201236503"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":4.48,"providers":[{"billed_charge":33.84,"npi":[1225110497]}]}]}]},{"name":"N.gonorrhoeae dna amp prob","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87591","description":"N.gonorrhoeae dna amp prob","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.11,"providers":[{"billed_charge":121.72,"npi":[1063497451]}]}]}]},{"name":"N.gonorrhoeae dna amp prob","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87591","description":"N.gonorrhoeae dna amp prob","allowed_amounts":[{"tin":{"type":"ein","value":"621433252"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":38.60,"providers":[{"billed_charge":70.18,"npi":[1689639544]}]}]}]},{"name":"Prothrombin time","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85610","description":"Prothrombin time","allowed_amounts":[{"tin":{"type":"ein","value":"201236503"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":2.27,"providers":[{"billed_charge":17.16,"npi":[1225110497]}]}]}]},{"name":"Psytx pt&\/family 60 minutes","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90837","description":"Psytx pt&\/family 60 minutes","allowed_amounts":[{"tin":{"type":"ein","value":"834016582"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":165.00,"providers":[{"billed_charge":165.00,"npi":[1083071542]}]}]}]},{"name":"Psytx pt&\/family 60 minutes","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9083795","description":"Psytx pt&\/family 60 minutes","allowed_amounts":[{"tin":{"type":"ein","value":"834016582"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":151.82,"providers":[{"billed_charge":165.00,"npi":[1083071542]}]},{"allowed_amount":152.00,"providers":[{"billed_charge":165.00,"npi":[1083071542]}]},{"allowed_amount":165.00,"providers":[{"billed_charge":165.00,"npi":[1083071542]}]}]}]},{"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":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"201236503"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":34.28,"npi":[1225110497]}]}]}]},{"name":"Subsequent hospital care","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99232","description":"Subsequent hospital care","allowed_amounts":[{"tin":{"type":"ein","value":"232589322"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":164.20,"providers":[{"billed_charge":490.00,"npi":[1245088509]}]}]}]},{"name":"Total cortisol","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82533","description":"Total cortisol","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":20.96,"providers":[{"billed_charge":102.90,"npi":[1063497451]}]}]}]},{"name":"Urinalysis auto w\/o scope","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81003","description":"Urinalysis auto w\/o scope","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":2.89,"providers":[{"billed_charge":21.17,"npi":[1063497451]}]}]}]},{"name":"Urinalysis auto w\/scope","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81001","description":"Urinalysis auto w\/scope","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":4.07,"providers":[{"billed_charge":37.80,"npi":[1063497451]}]}]}]},{"name":"Urine culture\/colony count","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87086","description":"Urine culture\/colony count","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":10.37,"providers":[{"billed_charge":86.98,"npi":[1063497451]}]}]}]},{"name":"Vitamin b-12","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82607","description":"Vitamin b-12","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":19.37,"providers":[{"billed_charge":111.30,"npi":[1063497451]}]}]}]},{"name":"Vitamin d 25 hydroxy","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82306","description":"Vitamin d 25 hydroxy","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":38.04,"providers":[{"billed_charge":286.65,"npi":[1063497451]}]}]}]}]}
