{"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":"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":7.44,"providers":[{"billed_charge":117.59,"npi":[1881679751]}]}]}]},{"name":"Assay of apolipoprotein","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82172","description":"Assay of apolipoprotein","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":39.82,"providers":[{"billed_charge":97.65,"npi":[1538144910]}]}]}]},{"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":78.67,"npi":[1063497451]},{"billed_charge":82.95,"npi":[1063497451,1538144910]}]}]}]},{"name":"Assay of folic acid serum","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82746","description":"Assay of folic acid serum","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":18.90,"providers":[{"billed_charge":104.21,"npi":[1538144910]},{"billed_charge":106.74,"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":[1538144910]},{"billed_charge":62.40,"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":[1063497451,1538144910]},{"billed_charge":56.26,"npi":[1063497451]}]}]}]},{"name":"Assay of lipoprotein(a)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83695","description":"Assay of lipoprotein(a)","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":16.65,"providers":[{"billed_charge":151.20,"npi":[1538144910]}]}]}]},{"name":"Assay of total thyroxine","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84436","description":"Assay of total thyroxine","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.84,"providers":[{"billed_charge":45.96,"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":"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":6.65,"providers":[{"billed_charge":108.29,"npi":[1881679751]}]}]}]},{"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":112.37,"npi":[1063497451]}]}]}]},{"name":"Behav hlth day treat, per hr","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"H2012","description":"Behav hlth day treat, per hr","allowed_amounts":[{"tin":{"type":"ein","value":"843798890"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":5332.50,"providers":[{"billed_charge":5925.00,"npi":[1417588203]}]}]}]},{"name":"Brief emotional\/behav assmt","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96127","description":"Brief emotional\/behav assmt","allowed_amounts":[{"tin":{"type":"ein","value":"452785676"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":4.92,"providers":[{"billed_charge":19.55,"npi":[1538307038]}]}]}]},{"name":"C-reactive protein hs","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86141","description":"C-reactive protein hs","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":16.65,"providers":[{"billed_charge":74.55,"npi":[1538144910]}]}]}]},{"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":"Diast bp 80-89 mm hg","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"3079F","description":"Diast bp 80-89 mm hg","allowed_amounts":[{"tin":{"type":"ein","value":"520595110"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1376581389]}]}]}]},{"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":"204100362"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":299.13,"providers":[{"billed_charge":1524.00,"npi":[1710376173]}]}]}]},{"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":"272134141"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":356.13,"providers":[{"billed_charge":2331.00,"npi":[1689944951]}]}]}]},{"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":[1538144910]}]}]}]},{"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":21.77,"providers":[{"billed_charge":287.24,"npi":[1881679751]}]}]}]},{"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":[1063497451,1538144910]},{"billed_charge":256.34,"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.18,"providers":[{"billed_charge":220.04,"npi":[1881679751]}]}]}]},{"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":[1063497451,1538144910]}]}]}]},{"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":12.46,"providers":[{"billed_charge":107.69,"npi":[1881679751]}]}]}]},{"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":34.48,"npi":[1063497451]},{"billed_charge":44.62,"npi":[1063497451,1538144910]}]}]}]},{"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":105.82,"npi":[1063497451]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":10.88,"providers":[{"billed_charge":43.94,"npi":[1063497451]}]}]}]},{"name":"Microsomal antibody each","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86376","description":"Microsomal antibody each","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":18.71,"providers":[{"billed_charge":103.95,"npi":[1538144910]}]}]}]},{"name":"Microsomal antibody each","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86376","description":"Microsomal antibody each","allowed_amounts":[{"tin":{"type":"ein","value":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":18.71,"providers":[{"billed_charge":128.69,"npi":[1881679751]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99212","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"520595110"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":55.16,"providers":[{"billed_charge":181.00,"npi":[1376581389]}]}]}]},{"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":"452752948"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":87.60,"providers":[{"billed_charge":150.00,"npi":[1578526091]}]}]}]},{"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":"452785676"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":79.03,"providers":[{"billed_charge":156.00,"npi":[1346344520]}]}]}]},{"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":"150532221"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":174.63,"providers":[{"billed_charge":272.24,"npi":[1669580361]}]}]}]},{"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":"520595110"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":239.06,"providers":[{"billed_charge":407.00,"npi":[1841696655]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9921495","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"251727721"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":174.63,"providers":[{"billed_charge":252.00,"npi":[1932176781]}]}]}]},{"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":"824335550"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":158.51,"providers":[{"billed_charge":200.00,"npi":[1457805046]}]}]}]},{"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":"824335550"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":148.01,"providers":[{"billed_charge":200.00,"npi":[1457805046]}]}]}]},{"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":"316025986"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":8.00,"npi":[1326657099]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":2.75,"providers":[{"billed_charge":56.22,"npi":[1881679751]}]}]}]},{"name":"Thyroglobulin antibody","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86800","description":"Thyroglobulin antibody","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":20.43,"providers":[{"billed_charge":107.10,"npi":[1538144910]}]}]}]},{"name":"Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and\/o","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G2211","description":"Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and\/o","allowed_amounts":[{"tin":{"type":"ein","value":"452785676"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":29.00,"npi":[1346344520]}]}]}]},{"name":"Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and\/o","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G221195","description":"Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and\/o","allowed_amounts":[{"tin":{"type":"ein","value":"251727721"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":44.00,"npi":[1932176781]}]}]}]},{"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":106.84,"npi":[1538144910]},{"billed_charge":115.40,"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":19.37,"providers":[{"billed_charge":150.74,"npi":[1881679751]}]}]}]},{"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":[1063497451,1538144910]},{"billed_charge":289.54,"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":38.04,"providers":[{"billed_charge":273.59,"npi":[1881679751]}]}]}]}]}