{"reporting_entity_name": "GIIC_TPA","reporting_entity_type": "GIIC_TPA","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"name":"Body mass index docd","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"3008F","description":"Body mass index docd","allowed_amounts":[{"tin":{"type":"ein","value":"362657618"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1457882946,1801863253,1902891377]}]}]}]},{"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":"843016042"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":6.85,"providers":[{"billed_charge":81.00,"npi":[1598315574]}]},{"allowed_amount":8.93,"providers":[{"billed_charge":81.00,"npi":[1598315574]}]}]}]},{"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":"843016042"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.84,"providers":[{"billed_charge":140.00,"npi":[1598315574]}]},{"allowed_amount":12.14,"providers":[{"billed_charge":140.00,"npi":[1598315574]}]}]}]},{"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":"843016042"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":13.53,"providers":[{"billed_charge":160.00,"npi":[1598315574]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99213","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"362657618"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":166.51,"providers":[{"billed_charge":184.00,"npi":[1902891377]}]}]}]},{"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":"362657618"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":234.77,"providers":[{"billed_charge":259.00,"npi":[1457882946]}]}]}]},{"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":"201220522"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":106.00,"providers":[{"billed_charge":225.00,"npi":[1497059349]}]}]}]},{"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":"362657618"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1457882946,1801863253,1902891377]}]}]}]},{"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":"843016042"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":3.64,"providers":[{"billed_charge":75.00,"npi":[1598315574]}]}]}]}]}
