{"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 ferritin","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82728","description":"Assay of ferritin","allowed_amounts":[{"tin":{"type":"ein","value":"250969492"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":52.65,"providers":[{"billed_charge":117.00,"npi":[1588269898]}]}]}]},{"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":137.84,"npi":[1063497451]}]}]}]},{"name":"Assay of lipase","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83690","description":"Assay of lipase","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.85,"providers":[{"billed_charge":51.45,"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":124.19,"npi":[1063497451]}]}]}]},{"name":"Complete cbc automated","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85027","description":"Complete cbc automated","allowed_amounts":[{"tin":{"type":"ein","value":"250969492"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":24.75,"providers":[{"billed_charge":55.00,"npi":[1588269898]}]}]}]},{"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":"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":"160743209"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":7.30,"providers":[{"billed_charge":45.00,"npi":[1346285657]}]}]}]},{"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]},{"billed_charge":63.29,"npi":[1063497451]}]}]}]},{"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":"160743209"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":107.56,"providers":[{"billed_charge":80.00,"npi":[1346285657]}]}]}]},{"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":"160743209"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":58.41,"providers":[{"billed_charge":111.00,"npi":[1346285657]}]}]}]},{"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":244.90,"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":69.30,"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":"160743209"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":9.13,"providers":[{"billed_charge":53.00,"npi":[1346285657]}]}]}]},{"name":"Hepatitis c ab test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86803","description":"Hepatitis c ab test","allowed_amounts":[{"tin":{"type":"ein","value":"250969492"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":54.90,"providers":[{"billed_charge":122.00,"npi":[1588269898]}]}]}]},{"name":"Hydration iv infusion init","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96360","description":"Hydration iv infusion init","allowed_amounts":[{"tin":{"type":"ein","value":"932671027"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1215610282]},{"billed_charge":132.00,"npi":[1215610282]}]}]}]},{"name":"IAAD IA HIV-1 AG W\/HIV-1 & HIV-2 ANTBDY SINGLE","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87389","description":"IAAD IA HIV-1 AG W\/HIV-1 & HIV-2 ANTBDY SINGLE","allowed_amounts":[{"tin":{"type":"ein","value":"250969492"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":92.70,"providers":[{"billed_charge":206.00,"npi":[1588269898]}]}]}]},{"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":112.64,"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":"160743209"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":7.95,"providers":[{"billed_charge":46.00,"npi":[1346285657]}]}]}]},{"name":"Normal saline solution infus","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J7030","description":"Normal saline solution infus","allowed_amounts":[{"tin":{"type":"ein","value":"932671027"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":1.99,"providers":[{"billed_charge":5.00,"npi":[1215610282]}]}]}]},{"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":"800348943"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":111.56,"providers":[{"billed_charge":180.00,"npi":[1336516665]}]}]}]},{"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":"526002033"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":100.86,"providers":[{"billed_charge":138.61,"npi":[1407815749]}]}]}]},{"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":"810721619"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":150.68,"providers":[{"billed_charge":360.00,"npi":[1902911704]}]}]}]},{"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":"840593455"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":160.21,"providers":[{"billed_charge":258.00,"npi":[1598755506]}]}]}]},{"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":"160743209"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":10.00,"npi":[1346285657]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"250969492"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":78.00,"npi":[1588269898]}]}]}]},{"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":85.75,"providers":[{"billed_charge":85.75,"npi":[1992326730]}]}]}]},{"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":122.09,"npi":[1063497451]}]}]}]},{"name":"Treponema pallidum","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86780","description":"Treponema pallidum","allowed_amounts":[{"tin":{"type":"ein","value":"250969492"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":50.85,"providers":[{"billed_charge":113.00,"npi":[1588269898]}]}]}]},{"name":"Urine culture\/colony count","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87086","description":"Urine culture\/colony count","allowed_amounts":[{"tin":{"type":"ein","value":"250969492"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":31.05,"providers":[{"billed_charge":69.00,"npi":[1588269898]}]}]}]},{"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":126.29,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":38.04,"providers":[{"billed_charge":301.64,"npi":[1063497451]}]}]}]}]}