{"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 lipase","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83690","description":"Assay of lipase","allowed_amounts":[{"tin":{"type":"ein","value":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":33.55,"providers":[{"billed_charge":69.00,"npi":[1528052578]}]}]}]},{"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":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":43.77,"providers":[{"billed_charge":90.00,"npi":[1528052578]}]}]}]},{"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":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":113.79,"providers":[{"billed_charge":234.00,"npi":[1528052578]}]}]}]},{"name":"Emergency Dept Visit","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9928425","description":"Emergency Dept Visit","allowed_amounts":[{"tin":{"type":"ein","value":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":486.30,"providers":[{"billed_charge":1000.00,"npi":[1528052578]}]}]}]},{"name":"Hydrate iv infusion add-on","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96361","description":"Hydrate iv infusion add-on","allowed_amounts":[{"tin":{"type":"ein","value":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":35.01,"providers":[{"billed_charge":72.00,"npi":[1528052578]}]}]}]},{"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":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":8.15,"providers":[{"billed_charge":16.75,"npi":[1528052578]}]}]}]},{"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":"232919472"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":143.34,"providers":[{"billed_charge":168.00,"npi":[1417923871]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9921395","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"232919472"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":143.34,"providers":[{"billed_charge":168.00,"npi":[1417923871]}]}]}]},{"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":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":8.15,"providers":[{"billed_charge":16.75,"npi":[1528052578]}]}]}]},{"name":"Ther\/proph\/diag inj iv push","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96374","description":"Ther\/proph\/diag inj iv push","allowed_amounts":[{"tin":{"type":"ein","value":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":158.53,"providers":[{"billed_charge":326.00,"npi":[1528052578]}]}]}]},{"name":"Tx\/pro\/dx inj new drug addon","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96375","description":"Tx\/pro\/dx inj new drug addon","allowed_amounts":[{"tin":{"type":"ein","value":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":36.47,"providers":[{"billed_charge":75.00,"npi":[1528052578]}]}]}]},{"name":"Urinalysis auto w\/scope","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81001","description":"Urinalysis auto w\/scope","allowed_amounts":[{"tin":{"type":"ein","value":"621114867"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":15.56,"providers":[{"billed_charge":32.00,"npi":[1528052578]}]}]}]}]}
