{"reporting_entity_name": "GIIC_TPA","reporting_entity_type": "GIIC_TPA","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"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":101.90,"npi":[1063497451]},{"billed_charge":122.85,"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":51.84,"npi":[1063497451]}]}]}]},{"name":"Assay of parathormone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83970","description":"Assay of parathormone","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":53.05,"providers":[{"billed_charge":172.20,"npi":[1063497451]},{"billed_charge":200.61,"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":"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":13.60,"providers":[{"billed_charge":48.30,"npi":[1255314704]}]}]}]},{"name":"Drug test def 1-7 classes","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0480","description":"Drug test def 1-7 classes","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":72.48,"providers":[{"billed_charge":401.73,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":71.85,"providers":[{"billed_charge":109.35,"npi":[1063497451]}]}]}]},{"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":"232624943"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":478.56,"providers":[{"billed_charge":879.00,"npi":[1619297140]}]}]}]},{"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":180.12,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.18,"providers":[{"billed_charge":259.72,"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":82.29,"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":177.08,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":2.75,"providers":[{"billed_charge":26.25,"npi":[1063497451]},{"billed_charge":39.26,"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":2.75,"providers":[{"billed_charge":26.25,"npi":[1255314704]}]}]}]},{"name":"Tb test cell immun measure","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86480","description":"Tb test cell immun measure","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":79.66,"providers":[{"billed_charge":251.34,"npi":[1063497451]}]}]}]},{"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":[1063497451]},{"billed_charge":192.44,"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":111.30,"npi":[1255314704]}]}]}]},{"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":299.64,"npi":[1063497451]}]}]}]}]}