{"reporting_entity_name": "GQO_PPO","reporting_entity_type": "GQO_PPO","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":62.78,"npi":[1063497451]},{"billed_charge":68.20,"npi":[1063497451]},{"billed_charge":71.53,"npi":[1063497451]}]}]}]},{"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":"232716811"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":1000.00,"providers":[{"billed_charge":1000.00,"npi":[1528054699]}]}]}]},{"name":"Antinuclear antibodies","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86038","description":"Antinuclear antibodies","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":15.53,"providers":[{"billed_charge":90.30,"npi":[1063497451]}]}]}]},{"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":19.91,"providers":[{"billed_charge":162.03,"npi":[1538144910]}]}]}]},{"name":"Assay of ck (cpk)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82550","description":"Assay of ck (cpk)","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.36,"providers":[{"billed_charge":38.85,"npi":[1063497451]}]}]}]},{"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":82.95,"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":66.04,"npi":[1063497451]},{"billed_charge":68.23,"npi":[1063497451]},{"billed_charge":80.97,"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":33.05,"npi":[1063497451]}]}]}]},{"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]},{"billed_charge":117.60,"npi":[1063497451]}]}]}]},{"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":52.53,"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":56.10,"npi":[1063497451]},{"billed_charge":60.95,"npi":[1063497451]},{"billed_charge":63.92,"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]},{"billed_charge":115.77,"npi":[1063497451]}]}]}]},{"name":"C-reactive protein","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86140","description":"C-reactive protein","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":6.65,"providers":[{"billed_charge":84.00,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":9.99,"providers":[{"billed_charge":32.55,"npi":[1063497451]},{"billed_charge":37.80,"npi":[1063497451]},{"billed_charge":39.11,"npi":[1063497451]},{"billed_charge":41.30,"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":100.26,"npi":[1063497451]},{"billed_charge":48.30,"npi":[1063497451]},{"billed_charge":53.55,"npi":[1063497451]},{"billed_charge":54.86,"npi":[1063497451]},{"billed_charge":57.05,"npi":[1063497451]}]}]}]},{"name":"Cytopath c\/v auto fluid redo","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"88175","description":"Cytopath c\/v auto fluid redo","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":34.05,"providers":[{"billed_charge":160.02,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":72.48,"providers":[{"billed_charge":159.60,"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":30.45,"providers":[{"billed_charge":30.45,"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":"273953335"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":572.78,"providers":[{"billed_charge":1870.00,"npi":[1700831302]}]}]}]},{"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":198.80,"npi":[1063497451]},{"billed_charge":199.73,"npi":[1063497451]},{"billed_charge":231.93,"npi":[1063497451]},{"billed_charge":259.98,"npi":[1063497451]},{"billed_charge":262.17,"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]},{"billed_charge":74.55,"npi":[1063497451]},{"billed_charge":75.86,"npi":[1063497451]},{"billed_charge":75.87,"npi":[1063497451]},{"billed_charge":78.05,"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":"232716811"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":150.00,"providers":[{"billed_charge":150.00,"npi":[1528054699]}]}]}]},{"name":"Hpv high-risk types","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87624","description":"Hpv high-risk types","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":47.94,"providers":[{"billed_charge":152.88,"npi":[1063497451]}]}]}]},{"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":44.65,"npi":[1063497451]}]}]}]},{"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":108.15,"npi":[1063497451]},{"billed_charge":109.46,"npi":[1063497451]},{"billed_charge":111.65,"npi":[1063497451]},{"billed_charge":129.15,"npi":[1063497451]}]}]}]},{"name":"Microbe susceptible mic","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87186","description":"Microbe susceptible mic","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.11,"providers":[{"billed_charge":88.20,"npi":[1063497451]}]}]}]},{"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":"831838249"},"service_code":["50"],"billing_class":"professional","payments":[{"allowed_amount":125.77,"providers":[{"billed_charge":325.00,"npi":[1639646789]}]}]}]},{"name":"Pharmacy","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0250","description":"Pharmacy","allowed_amounts":[{"tin":{"type":"ein","value":"332264068"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":2056.24,"npi":[1174331029]}]}]}]},{"name":"Prothrombin time","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85610","description":"Prothrombin time","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":5.05,"providers":[{"billed_charge":37.80,"npi":[1063497451]}]}]}]},{"name":"Rbc sed rate automated","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85652","description":"Rbc sed rate automated","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":3.47,"providers":[{"billed_charge":37.80,"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]}]}]}]},{"name":"Total cortisol","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82533","description":"Total cortisol","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":62.88,"providers":[{"billed_charge":308.70,"npi":[1063497451]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":4.07,"providers":[{"billed_charge":32.55,"npi":[1063497451]}]}]}]},{"name":"Urine bacteria culture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87088","description":"Urine bacteria culture","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":10.39,"providers":[{"billed_charge":37.86,"npi":[1063497451]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":10.37,"providers":[{"billed_charge":37.74,"npi":[1063497451]}]}]}]},{"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":"831838249"},"service_code":["50"],"billing_class":"professional","payments":[{"allowed_amount":16.33,"providers":[{"billed_charge":42.00,"npi":[1639646789]}]}]}]},{"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":111.30,"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":286.65,"npi":[1063497451]}]}]}]}]}
