{"reporting_entity_name": "GQO_PPO","reporting_entity_type": "GQO_PPO","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":"A0429SH","description":"Ambulance Service Basic Life Support\/Emergency","allowed_amounts":[{"tin":{"type":"ein","value":"820987228"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":432.03,"providers":[{"billed_charge":893.67,"npi":[1578171666]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427RH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"820987228"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":513.04,"providers":[{"billed_charge":1442.00,"npi":[1578171666]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427RH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"882108476"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":713.13,"providers":[{"billed_charge":1450.00,"npi":[1154069433]}]}]}]},{"name":"Body mass index docd","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"3008F","description":"Body mass index docd","allowed_amounts":[{"tin":{"type":"ein","value":"522011066"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1922113034]}]}]}]},{"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":"550357045"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":103.55,"providers":[{"billed_charge":109.00,"npi":[1144228305]}]}]}]},{"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":"550357045"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":73.15,"providers":[{"billed_charge":77.00,"npi":[1144228305]}]}]}]},{"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":"823697883"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":5.59,"providers":[{"billed_charge":66.60,"npi":[1699235374]}]}]}]},{"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":"550357045"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":93.10,"providers":[{"billed_charge":98.00,"npi":[1144228305]}]}]}]},{"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":"823697883"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":7.60,"providers":[{"billed_charge":90.91,"npi":[1699235374]}]}]}]},{"name":"Diast bp 80-89 mm hg","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"3079F","description":"Diast bp 80-89 mm hg","allowed_amounts":[{"tin":{"type":"ein","value":"522011066"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1922113034]}]}]}]},{"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":"550357045"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":257.27,"providers":[{"billed_charge":267.00,"npi":[1285050708]}]}]}]},{"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":"464821403"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":797.70,"providers":[{"billed_charge":1750.88,"npi":[1275604613]}]}]}]},{"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":"820987228"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":9.15,"providers":[{"billed_charge":33.61,"npi":[1578171666]}]}]}]},{"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":"882108476"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":84.00,"providers":[{"billed_charge":101.50,"npi":[1154069433]}]}]}]},{"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":"820987228"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":9.15,"providers":[{"billed_charge":35.59,"npi":[1578171666]}]}]}]},{"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":"232730785"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":94.07,"providers":[{"billed_charge":119.00,"npi":[1396211686]}]}]}]},{"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":"251665805"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":84.77,"providers":[{"billed_charge":125.00,"npi":[1093713968]}]}]}]},{"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":"522011066"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":92.98,"providers":[{"billed_charge":182.00,"npi":[1922113034]}]}]}]},{"name":"Pharmacy","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0250","description":"Pharmacy","allowed_amounts":[{"tin":{"type":"ein","value":"823697883"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1075.00,"providers":[{"billed_charge":12.53,"npi":[1699235374]}]}]}]},{"name":"Pharmacy - iv solutions","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0258","description":"Pharmacy - iv solutions","allowed_amounts":[{"tin":{"type":"ein","value":"550357045"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":8.12,"providers":[{"billed_charge":8.55,"npi":[1144228305]}]}]}]},{"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":"550357045"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":27.55,"providers":[{"billed_charge":29.00,"npi":[1144228305]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"550357045"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":18.00,"npi":[1144228305]}]}]}]},{"name":"Syst bp ge 130 - 139mm hg","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"3075F","description":"Syst bp ge 130 - 139mm hg","allowed_amounts":[{"tin":{"type":"ein","value":"522011066"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1922113034]}]}]}]},{"name":"Ther\/proph\/diag iv inf init","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96365","description":"Ther\/proph\/diag iv inf init","allowed_amounts":[{"tin":{"type":"ein","value":"550357045"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":1027.00,"npi":[1144228305]}]}]}]},{"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":"550357045"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":168.00,"npi":[1144228305]}]}]}]},{"name":"Urinalysis auto w\/o scope","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81003","description":"Urinalysis auto w\/o scope","allowed_amounts":[{"tin":{"type":"ein","value":"823697883"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1.62,"providers":[{"billed_charge":19.03,"npi":[1699235374]}]}]}]},{"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":"522011066"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":33.00,"npi":[1922113034]}]}]}]}]}