{"reporting_entity_name": "GIIC_TPA","reporting_entity_type": "GIIC_Geisinger Indemnity Insurance Company","last_updated_on": "2026-10-07","version": "2.0","provider_references": [                                                                                                                                                    
{"provider_group_id":475872327,"network_name":[],"provider_groups":[{"npi":[1225220478],"tin":{"type":"ein","value":"263010866","business_name":"Delaware Valley Aesthetics LLC"}}]}
], "in_network" : [
{"negotiation_arrangement":"ffs","name":"Grafting Of Autologous Fat Harvested By Liposuction Technique To Trunk_ Breasts_ Scalp_ Arms_ And/Or Legs; 50 Cc Or Less Injectate","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15771","description":"Grafting Of Autologous Fat Harvested By Liposuction Technique To Trunk_ Breasts_ Scalp_ Arms_ And/Or Legs; 50 Cc Or Less Injectate","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":5000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Revision of lower eyelid","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15820","description":"Revision of lower eyelid","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":6000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Revision of upper eyelid","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15822","description":"Revision of upper eyelid","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":6000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Removal of forehead wrinkles","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15824","description":"Removal of forehead wrinkles","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":10000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Suction lipectomy head&neck","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15876","description":"Suction lipectomy head&neck","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":5000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Removal of face wrinkles","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15828","description":"Removal of face wrinkles","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":10000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Suction lipectomy trunk","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15877","description":"Suction lipectomy trunk","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":9000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Suction lipectomy upr extrem","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15878","description":"Suction lipectomy upr extrem","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":6000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Suction lipectomy lwr extrem","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"15879","description":"Suction lipectomy lwr extrem","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":9000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Enlarge breast with implant","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"19325","description":"Enlarge breast with implant","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":4080.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Revise breast reconstruction","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"19380","description":"Revise breast reconstruction","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":7500.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Mast simple complete","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"19303","description":"Mast simple complete","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":5100.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Reduction of forehead","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"21137","description":"Reduction of forehead","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":8000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Lip surgery procedure","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"40799","description":"Lip surgery procedure","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":5750.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Reconstruction of nose","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"30410","description":"Reconstruction of nose","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":12000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Removal of testis","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"54520","description":"Removal of testis","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":4080.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Neck/chest surgery procedure","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"21899","description":"Neck/chest surgery procedure","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":5000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Reconstruction of chin","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"21120","description":"Reconstruction of chin","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":5000.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Sex transformation m to f","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"55970","description":"Sex transformation m to f","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":17340.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Office/outpatient visit new","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"99204","description":"Office/outpatient visit new","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"per diem","negotiated_rate":102.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Sex transformation f to m","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"55980","description":"Sex transformation f to m","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"percentage","negotiated_rate":80.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]},
{"negotiation_arrangement":"ffs","name":"Revise vag graft via vagina","billing_code_type":"CPT","billing_code_type_version":"2024","billing_code":"57295","description":"Revise vag graft via vagina","negotiated_rates":[{"negotiated_prices":[{"negotiated_type":"negotiated","negotiated_rate":12240.0,"expiration_date":"9999-12-31","service_code":["11"],"billing_class":"professional","setting":"outpatient"}],"provider_references":[475872327]}]}]}