{"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 Basic Life Support\/Emergency","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0429RH","description":"Ambulance Service Basic Life Support\/Emergency","allowed_amounts":[{"tin":{"type":"ein","value":"232840702"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":432.03,"providers":[{"billed_charge":981.25,"npi":[1003819103]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427SH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"316007293"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":521.00,"providers":[{"billed_charge":950.00,"npi":[1609863471]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427SH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"620694743"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":501.30,"providers":[{"billed_charge":650.00,"npi":[1134131915]}]}]}]},{"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":[1063497451]},{"billed_charge":80.97,"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":11.95,"providers":[{"billed_charge":31.37,"npi":[1396714663]}]}]}]},{"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":11.62,"providers":[{"billed_charge":30.50,"npi":[1396714663]}]}]}]},{"name":"Assay of psa total","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84153","description":"Assay of psa total","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":23.64,"providers":[{"billed_charge":112.35,"npi":[1063497451]}]}]}]},{"name":"Chiropract manj 1-2 regions","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"98940","description":"Chiropract manj 1-2 regions","allowed_amounts":[{"tin":{"type":"ein","value":"562403146"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":35.36,"npi":[1215558051]}]}]}]},{"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":13.48,"providers":[{"billed_charge":35.38,"npi":[1396714663]}]}]}]},{"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":"Culture othr specimn aerobic","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87070","description":"Culture othr specimn aerobic","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.06,"providers":[{"billed_charge":86.10,"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":101.01,"providers":[{"billed_charge":265.07,"npi":[1396714663]}]}]}]},{"name":"Emergency Dept Visit","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9928425","description":"Emergency Dept Visit","allowed_amounts":[{"tin":{"type":"ein","value":"621113737"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":210.94,"providers":[{"billed_charge":3840.00,"npi":[1023055126]}]}]}]},{"name":"Emergency dept visit","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99284","description":"Emergency dept visit","allowed_amounts":[{"tin":{"type":"ein","value":"922122433"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":191.45,"providers":[{"billed_charge":678.00,"npi":[1083076145]}]}]}]},{"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":"311116049"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":336.30,"providers":[{"billed_charge":1268.00,"npi":[1811709660]}]}]}]},{"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":[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":190.05,"npi":[1063497451]},{"billed_charge":231.93,"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":"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":"232840702"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":82.35,"providers":[{"billed_charge":204.25,"npi":[1003819103]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425SH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"316007293"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":65.00,"providers":[{"billed_charge":80.00,"npi":[1609863471]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425SH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"620694743"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":27.45,"providers":[{"billed_charge":39.00,"npi":[1134131915]}]}]}]},{"name":"Hepatic function panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80076","description":"Hepatic function panel","allowed_amounts":[{"tin":{"type":"ein","value":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":14.20,"providers":[{"billed_charge":37.27,"npi":[1396714663]}]}]}]},{"name":"Hydrate iv infusion add-on","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96361","description":"Hydrate iv infusion add-on","allowed_amounts":[{"tin":{"type":"ein","value":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":141.00,"providers":[{"billed_charge":370.00,"npi":[1396714663]}]}]}]},{"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]}]}]}]},{"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":12.17,"providers":[{"billed_charge":31.94,"npi":[1396714663]}]}]}]},{"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":9.01,"providers":[{"billed_charge":23.64,"npi":[1396714663]}]},{"allowed_amount":18.02,"providers":[{"billed_charge":47.28,"npi":[1396714663]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9921395","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"161097588"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":442.61,"providers":[{"billed_charge":450.00,"npi":[1043405244]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9921395","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"462155766"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":65.84,"providers":[{"billed_charge":150.00,"npi":[1578723151]}]}]}]},{"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":"161097588"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":623.32,"providers":[{"billed_charge":635.00,"npi":[1043405244]}]}]}]},{"name":"Pharmacy","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0250","description":"Pharmacy","allowed_amounts":[{"tin":{"type":"ein","value":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":13.29,"providers":[{"billed_charge":34.88,"npi":[1396714663]}]}]}]},{"name":"Pharmacy","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0250","description":"Pharmacy","allowed_amounts":[{"tin":{"type":"ein","value":"621113737"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":3.48,"providers":[{"billed_charge":63.28,"npi":[1023055126]}]}]}]},{"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":12.30,"npi":[1396714663]}]},{"allowed_amount":4.69,"providers":[{"billed_charge":12.30,"npi":[1396714663]}]}]}]},{"name":"Ther\/Proph\/Diag Inj, Iv Push","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"96374XU","description":"Ther\/Proph\/Diag Inj, Iv Push","allowed_amounts":[{"tin":{"type":"ein","value":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":123.85,"providers":[{"billed_charge":325.00,"npi":[1396714663]}]}]}]},{"name":"Therapeutic Exercises","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97110GO","description":"Therapeutic Exercises","allowed_amounts":[{"tin":{"type":"ein","value":"251721021"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":94.92,"providers":[{"billed_charge":237.30,"npi":[1316996887]}]}]}]},{"name":"Tx\/pro\/dx inj new drug addon","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96375","description":"Tx\/pro\/dx inj new drug addon","allowed_amounts":[{"tin":{"type":"ein","value":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":209.60,"providers":[{"billed_charge":550.00,"npi":[1396714663]}]}]}]},{"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":5.50,"providers":[{"billed_charge":14.43,"npi":[1396714663]}]}]}]},{"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":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":14.02,"providers":[{"billed_charge":36.78,"npi":[1396714663]}]}]}]},{"name":"Urine pregnancy test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81025","description":"Urine pregnancy test","allowed_amounts":[{"tin":{"type":"ein","value":"310537122"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":13.45,"providers":[{"billed_charge":35.30,"npi":[1396714663]}]}]}]},{"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]}]}]}]}]}
