{"reporting_entity_name": "GQO_PPO","reporting_entity_type": "GQO_PPO","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"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]}]}]}]},{"name":"Brief emotional\/behav assmt","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96127","description":"Brief emotional\/behav assmt","allowed_amounts":[{"tin":{"type":"ein","value":"991211836"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":4.51,"providers":[{"billed_charge":7.00,"npi":[1114032901]}]}]}]},{"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":48.30,"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]}]}]}]},{"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]}]}]}]},{"name":"Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation suppor","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99152","description":"Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation suppor","allowed_amounts":[{"tin":{"type":"ein","value":"272838050"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":53.32,"providers":[{"billed_charge":178.00,"npi":[1104900448]}]}]}]},{"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":"991211836"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":67.71,"providers":[{"billed_charge":131.00,"npi":[1114032901]}]}]}]},{"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":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"991211836"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":2.64,"providers":[{"billed_charge":15.00,"npi":[1114032901]}]}]}]},{"name":"Tobacco non-user","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"1036F","description":"Tobacco non-user","allowed_amounts":[{"tin":{"type":"ein","value":"851040784"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1780145722]}]}]}]}]}