{"reporting_entity_name": "GIIC_TPA","reporting_entity_type": "GIIC_TPA","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"name":"Adhesive remover, wipes","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A4456","description":"Adhesive remover, wipes","allowed_amounts":[{"tin":{"type":"ein","value":"202536458"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":13.75,"providers":[{"billed_charge":13.75,"npi":[1477222834]}]}]}]},{"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":"232270478"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":600.52,"providers":[{"billed_charge":950.00,"npi":[1508892753]}]}]}]},{"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":"873721345"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":474.74,"providers":[{"billed_charge":3700.00,"npi":[1497413124]}]}]}]},{"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":"232128471"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":647.50,"providers":[{"billed_charge":925.00,"npi":[1518910827]}]}]}]},{"name":"Assay of estradiol","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82670","description":"Assay of estradiol","allowed_amounts":[{"tin":{"type":"ein","value":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":18.19,"providers":[{"billed_charge":81.00,"npi":[1346309549]}]}]}]},{"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":186.34,"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]}]}]}]},{"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":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":5.80,"providers":[{"billed_charge":49.00,"npi":[1346309549]}]}]}]},{"name":"Assay of gonadotropin (fsh)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83001","description":"Assay of gonadotropin (fsh)","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":23.90,"providers":[{"billed_charge":110.96,"npi":[1063497451]}]}]}]},{"name":"Assay of gonadotropin (fsh)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83001","description":"Assay of gonadotropin (fsh)","allowed_amounts":[{"tin":{"type":"ein","value":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":12.08,"providers":[{"billed_charge":54.00,"npi":[1346309549]}]}]}]},{"name":"Assay of gonadotropin (lh)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83002","description":"Assay of gonadotropin (lh)","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":23.82,"providers":[{"billed_charge":110.59,"npi":[1063497451]}]}]}]},{"name":"Assay of gonadotropin (lh)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83002","description":"Assay of gonadotropin (lh)","allowed_amounts":[{"tin":{"type":"ein","value":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":12.08,"providers":[{"billed_charge":54.00,"npi":[1346309549]}]}]}]},{"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]},{"billed_charge":53.20,"npi":[1063497451]}]}]}]},{"name":"Assay of lactic acid","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83605","description":"Assay of lactic acid","allowed_amounts":[{"tin":{"type":"ein","value":"042790311"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":11.65,"providers":[{"billed_charge":49.00,"npi":[1487655064]}]}]}]},{"name":"Assay of progesterone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84144","description":"Assay of progesterone","allowed_amounts":[{"tin":{"type":"ein","value":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":13.52,"providers":[{"billed_charge":60.00,"npi":[1346309549]}]}]}]},{"name":"Assay of prolactin","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84146","description":"Assay of prolactin","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":24.91,"providers":[{"billed_charge":165.90,"npi":[1063497451]}]}]}]},{"name":"Assay of sex hormone globul","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84270","description":"Assay of sex hormone globul","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":27.93,"providers":[{"billed_charge":144.29,"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":189.12,"npi":[1063497451]}]}]}]},{"name":"Assay thyroid stim hormone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84443","description":"Assay thyroid stim hormone","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":21.59,"providers":[{"billed_charge":109.20,"npi":[1063497451]}]}]}]},{"name":"Assay thyroid stim hormone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84443","description":"Assay thyroid stim hormone","allowed_amounts":[{"tin":{"type":"ein","value":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":10.95,"providers":[{"billed_charge":49.00,"npi":[1346309549]}]}]}]},{"name":"Chorionic gonadotropin test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84702","description":"Chorionic gonadotropin test","allowed_amounts":[{"tin":{"type":"ein","value":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":9.82,"providers":[{"billed_charge":44.00,"npi":[1346309549]}]}]}]},{"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":"570314381"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":25.58,"providers":[{"billed_charge":85.00,"npi":[1134172000]}]}]}]},{"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":"042790311"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":9.27,"providers":[{"billed_charge":39.00,"npi":[1487655064]}]}]}]},{"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":160.02,"npi":[1063497451]},{"billed_charge":99.75,"npi":[1063497451]}]}]}]},{"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":"042790311"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":58.49,"providers":[{"billed_charge":246.00,"npi":[1487655064]}]}]}]},{"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":"208817905"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":143.82,"providers":[{"billed_charge":914.00,"npi":[1629849302]}]}]}]},{"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":229.95,"npi":[1063497451]}]}]}]},{"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":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":11.11,"providers":[{"billed_charge":49.00,"npi":[1346309549]}]}]}]},{"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":194.43,"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":"161135059"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":38.79,"providers":[{"billed_charge":158.62,"npi":[1629001722]}]}]}]},{"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":"232128471"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":88.20,"providers":[{"billed_charge":126.00,"npi":[1518910827]}]}]}]},{"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":"232270478"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":165.34,"providers":[{"billed_charge":272.00,"npi":[1508892753]}]}]}]},{"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":"873721345"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":128.10,"providers":[{"billed_charge":298.00,"npi":[1497413124]}]}]}]},{"name":"Hpv high-risk types","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87624","description":"Hpv high-risk types","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":47.94,"providers":[{"billed_charge":152.88,"npi":[1063497451]}]}]}]},{"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":33.26,"npi":[1063497451]},{"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]},{"billed_charge":107.28,"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":"161135059"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":14.73,"providers":[{"billed_charge":69.10,"npi":[1629001722]}]}]}]},{"name":"Medical\/surgical supplies and devices","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0270","description":"Medical\/surgical supplies and devices","allowed_amounts":[{"tin":{"type":"ein","value":"570314381"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":40.62,"providers":[{"billed_charge":135.00,"npi":[1134172000]}]}]}]},{"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":"042790311"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":11.41,"providers":[{"billed_charge":48.00,"npi":[1487655064]}]}]}]},{"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":"570314381"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":25.58,"providers":[{"billed_charge":85.00,"npi":[1134172000]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99214","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"260700568"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":87.97,"providers":[{"billed_charge":152.09,"npi":[1972313419]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99214","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"262043323"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":89.96,"providers":[{"billed_charge":615.00,"npi":[1548203839]}]}]}]},{"name":"Ondansetron hcl injection","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J2405","description":"Ondansetron hcl injection","allowed_amounts":[{"tin":{"type":"ein","value":"042790311"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":3.45,"npi":[1487655064]}]}]}]},{"name":"Pharmacy","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0250","description":"Pharmacy","allowed_amounts":[{"tin":{"type":"ein","value":"042790311"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":20.56,"providers":[{"billed_charge":86.46,"npi":[1487655064]}]}]}]},{"name":"Prothrombin time","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85610","description":"Prothrombin time","allowed_amounts":[{"tin":{"type":"ein","value":"042790311"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":5.71,"providers":[{"billed_charge":24.00,"npi":[1487655064]}]}]}]},{"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":"HCPCS","billing_code_type_version":"2026","billing_code":"96374XU","description":"Ther\/Proph\/Diag Inj, Iv Push","allowed_amounts":[{"tin":{"type":"ein","value":"042790311"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":81.07,"providers":[{"billed_charge":341.00,"npi":[1487655064]}]}]}]},{"name":"Ther\/proph\/diag inj sc\/im","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96372","description":"Ther\/proph\/diag inj sc\/im","allowed_amounts":[{"tin":{"type":"ein","value":"843150686"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":20.33,"providers":[{"billed_charge":33.50,"npi":[1124804489]}]}]}]},{"name":"Tobacco non-user","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"1036F","description":"Tobacco non-user","allowed_amounts":[{"tin":{"type":"ein","value":"260700568"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1972313419]}]}]}]},{"name":"Transvaginal us non-ob","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"76830","description":"Transvaginal us non-ob","allowed_amounts":[{"tin":{"type":"ein","value":"943220415"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":104.17,"providers":[{"billed_charge":200.00,"npi":[1346309549]}]}]}]},{"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":36.93,"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":"161135059"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":3.49,"providers":[{"billed_charge":22.00,"npi":[1629001722]}]}]}]},{"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":"570314381"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":29.49,"providers":[{"billed_charge":98.00,"npi":[1134172000]}]}]}]},{"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":"570314381"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":32.80,"providers":[{"billed_charge":109.00,"npi":[1134172000]}]}]}]},{"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":"843150686"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":4.45,"providers":[{"billed_charge":20.00,"npi":[1124804489]}]}]}]},{"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]},{"billed_charge":291.00,"npi":[1063497451]}]}]}]}]}
