{"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":"275076418"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":600.00,"providers":[{"billed_charge":600.00,"npi":[1396097374]}]}]}]},{"name":"Assay of estradiol","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82670","description":"Assay of estradiol","allowed_amounts":[{"tin":{"type":"ein","value":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":63.52,"providers":[{"billed_charge":228.00,"npi":[1548226988]}]}]}]},{"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":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":20.92,"providers":[{"billed_charge":74.00,"npi":[1548226988]}]}]}]},{"name":"Assay of gonadotropin (fsh)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83001","description":"Assay of gonadotropin (fsh)","allowed_amounts":[{"tin":{"type":"ein","value":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":42.61,"providers":[{"billed_charge":152.00,"npi":[1548226988]}]}]}]},{"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":"871528012"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":222.02,"npi":[1912677295]}]},{"allowed_amount":28.46,"providers":[{"billed_charge":222.02,"npi":[1912677295]}]}]}]},{"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":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":38.73,"providers":[{"billed_charge":137.00,"npi":[1548226988]}]}]}]},{"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":"760010407"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1639679905,1780105056]}]}]}]},{"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":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":14.72,"providers":[{"billed_charge":53.00,"npi":[1548226988]}]}]}]},{"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":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":24.01,"providers":[{"billed_charge":86.00,"npi":[1548226988]}]}]}]},{"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":"871528012"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":294.81,"providers":[{"billed_charge":4580.50,"npi":[1912677295]}]},{"allowed_amount":587.22,"providers":[{"billed_charge":4580.50,"npi":[1912677295]}]}]}]},{"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":"872637354"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":263.28,"providers":[{"billed_charge":3500.00,"npi":[1013963859]}]}]}]},{"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":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":38.73,"providers":[{"billed_charge":138.00,"npi":[1548226988]}]}]}]},{"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":"382084239"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":36.37,"providers":[{"billed_charge":317.18,"npi":[1790721538]}]}]}]},{"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":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":22.47,"providers":[{"billed_charge":79.00,"npi":[1548226988]}]}]}]},{"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":"275076418"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":312.00,"providers":[{"billed_charge":312.00,"npi":[1396097374]}]}]}]},{"name":"Iv Infusion For Therapy\/Prophylaxis\/Diagnosis, Initial, Up To 1 Hour","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9636559","description":"Iv Infusion For Therapy\/Prophylaxis\/Diagnosis, Initial, Up To 1 Hour","allowed_amounts":[{"tin":{"type":"ein","value":"871528012"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":74.01,"providers":[{"billed_charge":1149.84,"npi":[1912677295]}]}]}]},{"name":"Lipid panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80061","description":"Lipid panel","allowed_amounts":[{"tin":{"type":"ein","value":"382084239"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":17.33,"providers":[{"billed_charge":177.90,"npi":[1790721538]}]}]}]},{"name":"Lipid panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80061","description":"Lipid panel","allowed_amounts":[{"tin":{"type":"ein","value":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":30.99,"providers":[{"billed_charge":109.00,"npi":[1548226988]}]}]}]},{"name":"Manual Therapy Techniques 1 Or More Regions 15 Min. Each","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97140GP","description":"Manual Therapy Techniques 1 Or More Regions 15 Min. Each","allowed_amounts":[{"tin":{"type":"ein","value":"251857035"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":50.05,"providers":[{"billed_charge":77.00,"npi":[1912967134]}]}]}]},{"name":"Neuromuscular Reeducation","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97112GP","description":"Neuromuscular Reeducation","allowed_amounts":[{"tin":{"type":"ein","value":"760545192"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":453.60,"providers":[{"billed_charge":756.00,"npi":[1083937593]}]}]}]},{"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":"871528012"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1.00,"providers":[{"billed_charge":15.54,"npi":[1912677295]}]}]}]},{"name":"Office\/Outpatient Visit, Est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9921325","description":"Office\/Outpatient Visit, Est","allowed_amounts":[{"tin":{"type":"ein","value":"760371249"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":69.83,"providers":[{"billed_charge":219.00,"npi":[1174983506,1508401969]}]},{"allowed_amount":97.76,"providers":[{"billed_charge":219.00,"npi":[1861489833]}]}]}]},{"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":"760371249"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":101.31,"providers":[{"billed_charge":310.00,"npi":[1174983506]}]}]}]},{"name":"Ondansetron hcl injection","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J2405","description":"Ondansetron hcl injection","allowed_amounts":[{"tin":{"type":"ein","value":"871528012"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":4.16,"npi":[1912677295]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"382084239"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":4.17,"providers":[{"billed_charge":38.22,"npi":[1790721538]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"746000949"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":36.00,"npi":[1548226988]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"871528012"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":7.22,"providers":[{"billed_charge":112.16,"npi":[1912677295]}]},{"allowed_amount":14.38,"providers":[{"billed_charge":112.16,"npi":[1912677295]}]}]}]},{"name":"Therapeutic Exercises","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97110GP","description":"Therapeutic Exercises","allowed_amounts":[{"tin":{"type":"ein","value":"251857035"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":41.90,"providers":[{"billed_charge":166.00,"npi":[1912967134]}]},{"allowed_amount":53.95,"providers":[{"billed_charge":83.00,"npi":[1912967134]}]},{"allowed_amount":107.90,"providers":[{"billed_charge":166.00,"npi":[1912967134]}]}]}]},{"name":"Therapeutic Exercises","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97110GP","description":"Therapeutic Exercises","allowed_amounts":[{"tin":{"type":"ein","value":"760545192"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":190.20,"providers":[{"billed_charge":317.00,"npi":[1083937593]}]},{"allowed_amount":570.60,"providers":[{"billed_charge":951.00,"npi":[1083937593]}]}]}]},{"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":"871528012"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":63.00,"providers":[{"billed_charge":978.82,"npi":[1912677295]}]}]}]},{"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":"760371249"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":30.00,"npi":[1174983506]}]}]}]}]}
