{"reporting_entity_name": "GIIC_TPA","reporting_entity_type": "GIIC_TPA","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"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":"232925322"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":518.07,"providers":[{"billed_charge":1200.00,"npi":[1528399656]}]}]}]},{"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":"232925322"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":13.86,"providers":[{"billed_charge":17.00,"npi":[1528399656]}]}]}]},{"name":"Manual Therapy Techniques 1 Or More Regions 15 Min. Each","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97140GP","description":"Manual Therapy Techniques 1 Or More Regions 15 Min. Each","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":2.93,"providers":[{"billed_charge":2.93,"npi":[1992326730]}]}]}]},{"name":"Neuromuscular Reeducation","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97112GP","description":"Neuromuscular Reeducation","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":28.58,"providers":[{"billed_charge":28.58,"npi":[1992326730]}]},{"allowed_amount":34.30,"providers":[{"billed_charge":34.30,"npi":[1992326730]}]}]}]},{"name":"Therapeutic Activities","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97530GP","description":"Therapeutic Activities","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":36.28,"providers":[{"billed_charge":36.28,"npi":[1992326730]}]},{"allowed_amount":72.56,"providers":[{"billed_charge":72.56,"npi":[1992326730]}]}]}]},{"name":"Therapeutic Exercises","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97110GP","description":"Therapeutic Exercises","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":28.58,"providers":[{"billed_charge":28.58,"npi":[1992326730]}]},{"allowed_amount":30.57,"providers":[{"billed_charge":30.57,"npi":[1992326730]}]},{"allowed_amount":98.22,"providers":[{"billed_charge":98.22,"npi":[1992326730]}]}]}]},{"name":"Waiver service, nos","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"T2025","description":"Waiver service, nos","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":19.75,"npi":[]},{"billed_charge":24.65,"npi":[]},{"billed_charge":24.75,"npi":[]},{"billed_charge":29.75,"npi":[]},{"billed_charge":35.70,"npi":[]},{"billed_charge":39.95,"npi":[]},{"billed_charge":391.94,"npi":[]},{"billed_charge":44.20,"npi":[]},{"billed_charge":442.44,"npi":[]},{"billed_charge":58.25,"npi":[]},{"billed_charge":60.00,"npi":[]},{"billed_charge":80.00,"npi":[]}]},{"allowed_amount":6.50,"providers":[{"billed_charge":39.95,"npi":[]}]},{"allowed_amount":19.75,"providers":[{"billed_charge":19.75,"npi":[]}]},{"allowed_amount":24.65,"providers":[{"billed_charge":24.65,"npi":[]}]},{"allowed_amount":24.75,"providers":[{"billed_charge":24.75,"npi":[]}]},{"allowed_amount":25.75,"providers":[{"billed_charge":29.75,"npi":[]}]},{"allowed_amount":29.75,"providers":[{"billed_charge":29.75,"npi":[]}]},{"allowed_amount":40.00,"providers":[{"billed_charge":40.00,"npi":[]}]},{"allowed_amount":41.75,"providers":[{"billed_charge":58.25,"npi":[]}]},{"allowed_amount":44.20,"providers":[{"billed_charge":44.20,"npi":[]}]},{"allowed_amount":58.25,"providers":[{"billed_charge":58.25,"npi":[]}]}]}]}]}