{"reporting_entity_name": "GQO_PPO","reporting_entity_type": "GQO_PPO","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"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":"570935917"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1003922436]}]}]}]},{"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":"800869616"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1437508579]}]}]}]},{"name":"Cont airway pressure device","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"E0601RR","description":"Cont airway pressure device","allowed_amounts":[{"tin":{"type":"ein","value":"233010026"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":60.90,"providers":[{"billed_charge":114.44,"npi":[1841397049]}]},{"allowed_amount":62.55,"providers":[{"billed_charge":114.44,"npi":[1841397049]}]}]}]},{"name":"Cytopath c\/v interpret","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"88141","description":"Cytopath c\/v interpret","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":21.26,"providers":[{"billed_charge":77.70,"npi":[1063497451]}]}]}]},{"name":"Emergency Dept Visit","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9928325","description":"Emergency Dept Visit","allowed_amounts":[{"tin":{"type":"ein","value":"273953335"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":750.00,"npi":[1932703022]}]}]}]},{"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":"273953335"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":205.20,"providers":[{"billed_charge":1280.00,"npi":[1972579225]}]}]}]},{"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":"621130266"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":142.48,"providers":[{"billed_charge":1141.00,"npi":[1750540084]}]}]}]},{"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":"824595729"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":195.06,"providers":[{"billed_charge":2392.00,"npi":[1649484890]}]}]}]},{"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":[1376599654]}]}]}]},{"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":"522103311"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":572.78,"providers":[{"billed_charge":1751.00,"npi":[1073923603]}]}]}]},{"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":213.15,"npi":[1063497451]}]}]}]},{"name":"Immunoassay tumor ca 19-9","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86301","description":"Immunoassay tumor ca 19-9","allowed_amounts":[{"tin":{"type":"ein","value":"043633263"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":429.58,"providers":[{"billed_charge":457.00,"npi":[1972503910]}]}]}]},{"name":"Med serv 10pm-8am 24 hr fac","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99053","description":"Med serv 10pm-8am 24 hr fac","allowed_amounts":[{"tin":{"type":"ein","value":"522103311"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":51.00,"npi":[1073923603]}]}]}]},{"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":"570935917"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":163.90,"providers":[{"billed_charge":298.00,"npi":[1003922436]}]}]}]},{"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":"800869616"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":131.15,"providers":[{"billed_charge":210.00,"npi":[1437508579]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"043633263"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":21.00,"npi":[1972503910]}]}]}]}]}
