{"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 ck (cpk)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82550","description":"Assay of ck (cpk)","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":120.00,"npi":[1730121633]}]}]}]},{"name":"Assay of free thyroxine","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84439","description":"Assay of free thyroxine","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":103.00,"npi":[1730121633]}]}]}]},{"name":"Assay of lactic acid","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83605","description":"Assay of lactic acid","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":106.00,"npi":[1730121633]}]}]}]},{"name":"Assay of lipase","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83690","description":"Assay of lipase","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":81.00,"npi":[1730121633]}]}]}]},{"name":"Assay of magnesium","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83735","description":"Assay of magnesium","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":63.00,"npi":[1730121633]}]}]}]},{"name":"Assay thyroid stim hormone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84443","description":"Assay thyroid stim hormone","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":197.00,"npi":[1730121633]}]}]}]},{"name":"Assay triiodothyronine (t3)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84480","description":"Assay triiodothyronine (t3)","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":118.00,"npi":[1730121633]}]}]}]},{"name":"C-reactive protein","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86140","description":"C-reactive protein","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":61.00,"npi":[1730121633]}]}]}]},{"name":"Chylmd trach dna amp probe","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87491","description":"Chylmd trach dna amp probe","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.11,"providers":[{"billed_charge":138.08,"npi":[1063497451]}]}]}]},{"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":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":93.00,"npi":[1730121633]}]}]}]},{"name":"Cultr bacteria except blood","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87075","description":"Cultr bacteria except blood","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":12.17,"providers":[{"billed_charge":131.43,"npi":[1063497451]}]}]}]},{"name":"Culture othr specimn aerobic","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87070","description":"Culture othr specimn aerobic","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.06,"providers":[{"billed_charge":119.52,"npi":[1063497451]}]}]}]},{"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":"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":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":426.00,"npi":[1730121633]}]}]}]},{"name":"General health panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80050","description":"General health panel","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.18,"providers":[{"billed_charge":190.05,"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":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":112.00,"npi":[1730121633]}]}]}]},{"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":"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":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":126.00,"npi":[1730121633]}]}]}]},{"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":"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":97.65,"npi":[1063497451]}]}]}]},{"name":"Metabolic panel total ca","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80048","description":"Metabolic panel total ca","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":196.00,"npi":[1730121633]}]}]}]},{"name":"Microbe susceptible mic","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87186","description":"Microbe susceptible mic","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.11,"providers":[{"billed_charge":88.20,"npi":[1063497451]}]}]}]},{"name":"N.gonorrhoeae dna amp prob","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87591","description":"N.gonorrhoeae dna amp prob","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.11,"providers":[{"billed_charge":138.08,"npi":[1063497451]}]}]}]},{"name":"Rbc sed rate automated","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"85652","description":"Rbc sed rate automated","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":33.00,"npi":[1730121633]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"043399616"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":16.00,"npi":[1730121633]}]}]}]}]}