{"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":"250965274"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":24.38,"providers":[{"billed_charge":75.00,"npi":[1447317896]}]}]}]},{"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":"250965274"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":26.01,"providers":[{"billed_charge":80.00,"npi":[1447317896]}]}]}]},{"name":"Dexamethasone sodium phos","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J1100","description":"Dexamethasone sodium phos","allowed_amounts":[{"tin":{"type":"ein","value":"341567805"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1.79,"providers":[{"billed_charge":3.23,"npi":[1043397292]}]}]}]},{"name":"Drug test def 1-7 classes","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0480","description":"Drug test def 1-7 classes","allowed_amounts":[{"tin":{"type":"ein","value":"250965274"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":401.00,"npi":[1447317896]}]}]}]},{"name":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT,","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80307","description":"Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT,","allowed_amounts":[{"tin":{"type":"ein","value":"250965274"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":400.00,"npi":[1447317896]}]}]}]},{"name":"Drugs unclassified injection","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J3490","description":"Drugs unclassified injection","allowed_amounts":[{"tin":{"type":"ein","value":"341567805"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":16.72,"npi":[1043397292]}]}]}]},{"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":"251643812"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":185.43,"providers":[{"billed_charge":424.00,"npi":[1235106931]}]}]}]},{"name":"Inj, propofol, 10 mg","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J2704","description":"Inj, propofol, 10 mg","allowed_amounts":[{"tin":{"type":"ein","value":"341567805"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":7.61,"providers":[{"billed_charge":13.71,"npi":[1043397292]}]}]}]},{"name":"Ketorolac tromethamine inj","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J1885JZ","description":"Ketorolac tromethamine inj","allowed_amounts":[{"tin":{"type":"ein","value":"341567805"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1.79,"providers":[{"billed_charge":3.23,"npi":[1043397292]}]}]}]},{"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":"161406947"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":81.20,"providers":[{"billed_charge":175.00,"npi":[1427444686]}]}]}]},{"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":"812838296"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":201.57,"providers":[{"billed_charge":315.00,"npi":[1164496717]}]}]}]},{"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":"341567805"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1.93,"providers":[{"billed_charge":3.48,"npi":[1043397292]}]}]}]},{"name":"Pharmacy","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0250","description":"Pharmacy","allowed_amounts":[{"tin":{"type":"ein","value":"341567805"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":5.47,"providers":[{"billed_charge":9.86,"npi":[1043397292]}]}]}]},{"name":"Therapeutic Activities","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97530GP","description":"Therapeutic Activities","allowed_amounts":[{"tin":{"type":"ein","value":"161406947"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":63.00,"npi":[1578599866]}]}]}]},{"name":"Therapeutic Exercises","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97110GP","description":"Therapeutic Exercises","allowed_amounts":[{"tin":{"type":"ein","value":"161406947"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":75.31,"providers":[{"billed_charge":126.00,"npi":[1578599866]}]}]}]}]}