{"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":"231597404"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":950.00,"providers":[{"billed_charge":950.00,"npi":[1578569075]}]}]}]},{"name":"Cytopath c\/v auto fluid redo","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"88175","description":"Cytopath c\/v auto fluid redo","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":34.05,"providers":[{"billed_charge":160.02,"npi":[1063497451]}]}]}]},{"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":152.88,"npi":[1063497451]}]}]}]},{"name":"Waiver service, nos","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"T2025","description":"Waiver service, nos","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":0.42,"providers":[{"billed_charge":25.29,"npi":[]}]},{"allowed_amount":25.29,"providers":[{"billed_charge":25.29,"npi":[]}]},{"allowed_amount":49.00,"providers":[{"billed_charge":49.00,"npi":[]}]}]}]}]}
