{"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,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427SH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"232714536"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":513.04,"providers":[{"billed_charge":1050.00,"npi":[1720058464]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.59,"providers":[{"billed_charge":80.97,"npi":[1063497451]}]}]}]},{"name":"Assay of psa total","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84153","description":"Assay of psa total","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":23.64,"providers":[{"billed_charge":112.35,"npi":[1063497451]}]}]}]},{"name":"Chorionic gonadotropin test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84702","description":"Chorionic gonadotropin test","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":19.34,"providers":[{"billed_charge":126.00,"npi":[1063497451]},{"billed_charge":152.25,"npi":[1063497451]}]}]}]},{"name":"Cptr ophth dx img post segmt","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"92134","description":"Cptr ophth dx img post segmt","allowed_amounts":[{"tin":{"type":"ein","value":"650017482"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":37.51,"providers":[{"billed_charge":300.00,"npi":[1891973673]}]}]}]},{"name":"Cptr ophth dx img post segmt","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"92134","description":"Cptr ophth dx img post segmt","allowed_amounts":[{"tin":{"type":"ein","value":"833293743"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":32.75,"providers":[{"billed_charge":68.00,"npi":[1346248887]}]}]}]},{"name":"Electric Stimulation Therapy","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97014GP","description":"Electric Stimulation Therapy","allowed_amounts":[{"tin":{"type":"ein","value":"251655314"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":10.00,"providers":[{"billed_charge":55.00,"npi":[1770500415]}]}]}]},{"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":[1932703022]}]}]}]},{"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":"522103311"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":205.20,"providers":[{"billed_charge":1218.00,"npi":[1073923603]}]}]}]},{"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":231.93,"npi":[1063497451]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425SH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"232714536"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":18.30,"providers":[{"billed_charge":40.30,"npi":[1720058464]}]}]}]},{"name":"Hot Or Cold Packs Therapy","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97010GP","description":"Hot Or Cold Packs Therapy","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":5.64,"npi":[1992326730]}]}]}]},{"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":102.90,"npi":[1063497451]}]}]}]},{"name":"Manual Therapy Techniques 1 Or More Regions 15 Min. Each","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97140GP","description":"Manual Therapy Techniques 1 Or More Regions 15 Min. Each","allowed_amounts":[{"tin":{"type":"ein","value":"251857035"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":50.05,"providers":[{"billed_charge":77.00,"npi":[1912967134]}]}]}]},{"name":"Manual Therapy Techniques 1 Or More Regions 15 Min. Each","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97140GP","description":"Manual Therapy Techniques 1 Or More Regions 15 Min. Each","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":19.23,"providers":[{"billed_charge":19.23,"npi":[1992326730]}]}]}]},{"name":"Neuromuscular Reeducation","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97112GP","description":"Neuromuscular Reeducation","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":31.15,"providers":[{"billed_charge":31.15,"npi":[1992326730]}]},{"allowed_amount":62.30,"providers":[{"billed_charge":62.30,"npi":[1992326730]}]}]}]},{"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":"391351587"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":92.16,"providers":[{"billed_charge":263.00,"npi":[1205881182]}]}]}]},{"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":"833293743"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":88.24,"providers":[{"billed_charge":150.00,"npi":[1346248887]}]}]}]},{"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":"454852156"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":206.96,"providers":[{"billed_charge":351.00,"npi":[1487723680,1689820672]}]}]}]},{"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":"833293743"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":123.83,"providers":[{"billed_charge":175.00,"npi":[1346248887]}]}]}]},{"name":"Physical therapy evaluation: low complexity","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97161GP","description":"Physical therapy evaluation: low complexity","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":71.42,"providers":[{"billed_charge":71.42,"npi":[1992326730]}]}]}]},{"name":"Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individu","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"G0070","description":"Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individu","allowed_amounts":[{"tin":{"type":"ein","value":"231352685"},"service_code":["12"],"billing_class":"professional","payments":[{"allowed_amount":505.00,"providers":[{"billed_charge":594.16,"npi":[1295438182]}]}]}]},{"name":"Psytx pt&\/family 60 minutes","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"90837","description":"Psytx pt&\/family 60 minutes","allowed_amounts":[{"tin":{"type":"ein","value":"999999999"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":300.00,"providers":[{"billed_charge":300.00,"npi":[]}]}]}]},{"name":"Radiologic examination, chest; 2 views","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"7104626","description":"Radiologic examination, chest; 2 views","allowed_amounts":[{"tin":{"type":"ein","value":"412007905"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":19.38,"providers":[{"billed_charge":41.00,"npi":[1699238329]}]}]}]},{"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":"Therapeutic Activities","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97530GP","description":"Therapeutic Activities","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":32.84,"providers":[{"billed_charge":32.84,"npi":[1992326730]}]}]}]},{"name":"Therapeutic Exercises","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97110GP","description":"Therapeutic Exercises","allowed_amounts":[{"tin":{"type":"ein","value":"251655314"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":62.85,"providers":[{"billed_charge":288.00,"npi":[1770500415]}]}]}]},{"name":"Therapeutic Exercises","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97110GP","description":"Therapeutic Exercises","allowed_amounts":[{"tin":{"type":"ein","value":"251857035"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":53.95,"providers":[{"billed_charge":83.00,"npi":[1912967134]}]}]}]},{"name":"Therapeutic Exercises","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97110GP","description":"Therapeutic Exercises","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":17.90,"providers":[{"billed_charge":17.90,"npi":[1992326730]}]},{"allowed_amount":29.82,"providers":[{"billed_charge":29.82,"npi":[1992326730]}]}]}]}]}