{"reporting_entity_name": "GQO_PPO","reporting_entity_type": "GQO_PPO","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"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]}]}]}]},{"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":[1679991012]}]}]}]},{"name":"Hepatic function panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80076","description":"Hepatic function panel","allowed_amounts":[{"tin":{"type":"ein","value":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":10.51,"providers":[{"billed_charge":48.30,"npi":[1740262880]}]}]}]},{"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":"852309826"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":142.41,"providers":[{"billed_charge":262.00,"npi":[1780097105]}]}]}]},{"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":"840611484"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":2.75,"providers":[{"billed_charge":26.25,"npi":[1740262880]}]}]}]},{"name":"Syphilis test non-trep qual","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86592","description":"Syphilis test non-trep qual","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":5.48,"providers":[{"billed_charge":40.95,"npi":[1063497451]}]}]}]},{"name":"Urine pregnancy test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81025","description":"Urine pregnancy test","allowed_amounts":[{"tin":{"type":"ein","value":"852309826"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":3.63,"providers":[{"billed_charge":17.00,"npi":[1780097105]}]}]}]}]}