{"reporting_entity_name": "GQO_PPO","reporting_entity_type": "GQO_PPO","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"name":"Albumin; urine (eg, microalbumin), quantitative","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82043","description":"Albumin; urine (eg, microalbumin), quantitative","allowed_amounts":[{"tin":{"type":"ein","value":"210635009"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":68.93,"providers":[{"billed_charge":184.00,"npi":[1689714255]}]}]}]},{"name":"Ambulance Service Basic Life Support\/Emergency","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0429RH","description":"Ambulance Service Basic Life Support\/Emergency","allowed_amounts":[{"tin":{"type":"ein","value":"237087869"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":606.42,"providers":[{"billed_charge":1100.00,"npi":[1679569735]}]},{"allowed_amount":1100.00,"providers":[{"billed_charge":1100.00,"npi":[1679569735]}]}]}]},{"name":"Assay of estradiol","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82670","description":"Assay of estradiol","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":35.91,"providers":[{"billed_charge":182.70,"npi":[1063497451]}]}]}]},{"name":"Assay of ferritin","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82728","description":"Assay of ferritin","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":17.50,"providers":[{"billed_charge":82.95,"npi":[1063497451]}]}]}]},{"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":106.05,"npi":[1932184322]},{"billed_charge":122.85,"npi":[1063497451]}]}]}]},{"name":"Assay of gonadotropin (fsh)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83001","description":"Assay of gonadotropin (fsh)","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":23.90,"providers":[{"billed_charge":112.35,"npi":[1063497451]}]}]}]},{"name":"Assay of gonadotropin (lh)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83002","description":"Assay of gonadotropin (lh)","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":23.82,"providers":[{"billed_charge":109.20,"npi":[1063497451]}]}]}]},{"name":"Assay of homocystine","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83090","description":"Assay of homocystine","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":21.69,"providers":[{"billed_charge":195.30,"npi":[1063497451]}]}]}]},{"name":"Assay of insulin","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83525","description":"Assay of insulin","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":14.70,"providers":[{"billed_charge":88.20,"npi":[1063497451]}]}]}]},{"name":"Assay of iron","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83540","description":"Assay of iron","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.32,"providers":[{"billed_charge":33.05,"npi":[1538144910]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":15.37,"providers":[{"billed_charge":71.00,"npi":[1396858999]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.85,"providers":[{"billed_charge":51.45,"npi":[1063497451]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":10.39,"providers":[{"billed_charge":48.00,"npi":[1396858999]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.61,"providers":[{"billed_charge":38.85,"npi":[1932184322]}]}]}]},{"name":"Assay of prolactin","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84146","description":"Assay of prolactin","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":24.91,"providers":[{"billed_charge":139.65,"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":"Assay of sex hormone globul","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84270","description":"Assay of sex hormone globul","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":27.93,"providers":[{"billed_charge":148.05,"npi":[1063497451]}]}]}]},{"name":"Assay of somatomedin","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84305","description":"Assay of somatomedin","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":27.32,"providers":[{"billed_charge":309.75,"npi":[1063497451]}]}]}]},{"name":"Assay of total testosterone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84403","description":"Assay of total testosterone","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":33.19,"providers":[{"billed_charge":162.75,"npi":[1063497451]}]}]}]},{"name":"Assay of urine creatinine","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82570","description":"Assay of urine creatinine","allowed_amounts":[{"tin":{"type":"ein","value":"210635009"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":64.06,"providers":[{"billed_charge":171.00,"npi":[1689714255]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":21.59,"providers":[{"billed_charge":98.70,"npi":[1932184322]}]}]}]},{"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":"141338307"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":5.44,"providers":[{"billed_charge":76.00,"npi":[1376577247]}]}]}]},{"name":"C-reactive protein hs","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86141","description":"C-reactive protein hs","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":16.65,"providers":[{"billed_charge":74.55,"npi":[1063497451]}]}]}]},{"name":"Chemo iv infusion 1 hr","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96413","description":"Chemo iv infusion 1 hr","allowed_amounts":[{"tin":{"type":"ein","value":"141338307"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":535.06,"providers":[{"billed_charge":904.00,"npi":[1376577247]}]}]}]},{"name":"Chemo iv infusion addl hr","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96415","description":"Chemo iv infusion addl hr","allowed_amounts":[{"tin":{"type":"ein","value":"141338307"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":114.53,"providers":[{"billed_charge":136.00,"npi":[1376577247]}]}]}]},{"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":[1538144910]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":15.59,"providers":[{"billed_charge":72.00,"npi":[1396858999]}]},{"allowed_amount":24.11,"providers":[{"billed_charge":72.00,"npi":[1396858999]}]},{"allowed_amount":25.19,"providers":[{"billed_charge":72.00,"npi":[1396858999]}]}]}]},{"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":"141338307"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":8.16,"providers":[{"billed_charge":130.00,"npi":[1376577247]}]}]}]},{"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":"250965420"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":35.00,"providers":[{"billed_charge":87.50,"npi":[1952311508]}]}]}]},{"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":"550643304"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":81.70,"providers":[{"billed_charge":86.00,"npi":[1841271459]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":37.02,"providers":[{"billed_charge":171.00,"npi":[1396858999]}]},{"allowed_amount":57.27,"providers":[{"billed_charge":171.00,"npi":[1396858999]}]}]}]},{"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":"141338307"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":11.09,"providers":[{"billed_charge":273.00,"npi":[1376577247]}]}]}]},{"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":"210635009"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":119.12,"providers":[{"billed_charge":318.00,"npi":[1689714255]}]}]}]},{"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":"250965420"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":693.20,"providers":[{"billed_charge":1733.00,"npi":[1952311508]}]}]}]},{"name":"Dehydroepiandrosterone","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82627","description":"Dehydroepiandrosterone","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":28.59,"providers":[{"billed_charge":175.35,"npi":[1063497451]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":1245.89,"providers":[{"billed_charge":3720.00,"npi":[1396858999]}]},{"allowed_amount":1301.50,"providers":[{"billed_charge":3720.00,"npi":[1396858999]}]},{"allowed_amount":1351.02,"providers":[{"billed_charge":6240.00,"npi":[1396858999]}]}]}]},{"name":"Free assay (ft-3)","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"84481","description":"Free assay (ft-3)","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":21.77,"providers":[{"billed_charge":229.95,"npi":[1063497451]}]}]}]},{"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":179.55,"npi":[1538144910]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":12.46,"providers":[{"billed_charge":69.30,"npi":[1063497451]}]}]}]},{"name":"Ground Mileage, Per Statute Mile","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0425RH","description":"Ground Mileage, Per Statute Mile","allowed_amounts":[{"tin":{"type":"ein","value":"237087869"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":182.00,"providers":[{"billed_charge":325.00,"npi":[1679569735]}]},{"allowed_amount":375.00,"providers":[{"billed_charge":375.00,"npi":[1679569735]}]}]}]},{"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":"210635009"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":101.89,"providers":[{"billed_charge":272.00,"npi":[1689714255]}]}]}]},{"name":"Hepatitis c ab test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86803","description":"Hepatitis c ab test","allowed_amounts":[{"tin":{"type":"ein","value":"210635009"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":176.06,"providers":[{"billed_charge":470.00,"npi":[1689714255]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":56.29,"providers":[{"billed_charge":260.00,"npi":[1396858999]}]},{"allowed_amount":90.97,"providers":[{"billed_charge":260.00,"npi":[1396858999]}]}]}]},{"name":"Iron binding test","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83550","description":"Iron binding test","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":11.24,"providers":[{"billed_charge":44.65,"npi":[1538144910]}]}]}]},{"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":"Lipid panel","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"80061","description":"Lipid panel","allowed_amounts":[{"tin":{"type":"ein","value":"210635009"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":75.29,"providers":[{"billed_charge":201.00,"npi":[1689714255]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":33.94,"providers":[{"billed_charge":97.00,"npi":[1396858999]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":10.88,"providers":[{"billed_charge":43.94,"npi":[1932184322]}]}]}]},{"name":"Microsomal antibody each","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86376","description":"Microsomal antibody each","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":18.71,"providers":[{"billed_charge":103.95,"npi":[1063497451]}]}]}]},{"name":"Neuromuscular Reeducation","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97112GO","description":"Neuromuscular Reeducation","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":30.67,"providers":[{"billed_charge":30.67,"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":75.38,"providers":[{"billed_charge":75.38,"npi":[1992326730]}]}]}]},{"name":"Normal saline solution infus","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"J7050","description":"Normal saline solution infus","allowed_amounts":[{"tin":{"type":"ein","value":"141338307"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.91,"providers":[{"billed_charge":8.50,"npi":[1376577247]}]}]}]},{"name":"Ob us follow-up per fetus","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"76816","description":"Ob us follow-up per fetus","allowed_amounts":[{"tin":{"type":"ein","value":"550492006"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":319.34,"providers":[{"billed_charge":389.00,"npi":[1720161961]}]}]}]},{"name":"Office\/Outpatient Visit, Est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9921325","description":"Office\/Outpatient Visit, Est","allowed_amounts":[{"tin":{"type":"ein","value":"550492006"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":152.99,"providers":[{"billed_charge":165.00,"npi":[1902646615]}]}]}]},{"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":"010372148"},"service_code":["22"],"billing_class":"professional","payments":[{"allowed_amount":106.25,"providers":[{"billed_charge":173.00,"npi":[1184130510]}]}]}]},{"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":"202935692"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":123.60,"providers":[{"billed_charge":141.00,"npi":[1396788733]}]}]}]},{"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":"272272976"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":95.44,"providers":[{"billed_charge":205.00,"npi":[1194039560]}]}]}]},{"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":"141338310"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":155.79,"providers":[{"billed_charge":382.00,"npi":[1538191101]}]}]}]},{"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":"202935692"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":180.25,"providers":[{"billed_charge":205.00,"npi":[1801058011]}]}]}]},{"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":"251898598"},"service_code":["02"],"billing_class":"professional","payments":[{"allowed_amount":82.32,"providers":[{"billed_charge":120.00,"npi":[1619255825]}]}]},{"tin":{"type":"ein","value":"251898598"},"service_code":["02","11"],"billing_class":"professional","payments":[{"allowed_amount":66.00,"providers":[{"billed_charge":120.00,"npi":[1164028817]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9921495","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"852938829"},"service_code":["02"],"billing_class":"professional","payments":[{"allowed_amount":147.72,"providers":[{"billed_charge":250.00,"npi":[1932607264]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":18.56,"npi":[1396858999]},{"billed_charge":9.28,"npi":[1396858999]}]}]}]},{"name":"Pharmacy","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0250","description":"Pharmacy","allowed_amounts":[{"tin":{"type":"ein","value":"210635009"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":35.13,"providers":[{"billed_charge":125.00,"npi":[1689714255]}]}]}]},{"name":"Psytx pt&\/fam w\/e&m 30 min","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9083395","description":"Psytx pt&\/fam w\/e&m 30 min","allowed_amounts":[{"tin":{"type":"ein","value":"852938829"},"service_code":["02"],"billing_class":"professional","payments":[{"allowed_amount":89.29,"providers":[{"billed_charge":250.00,"npi":[1932607264]}]}]}]},{"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":"141338307"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":2.84,"providers":[{"billed_charge":95.00,"npi":[1376577247]}]}]}]},{"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":[1538144910]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"141338307"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":9.54,"providers":[{"billed_charge":36.00,"npi":[1376577247]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"210635009"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":26.60,"providers":[{"billed_charge":71.00,"npi":[1689714255]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"550643304"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":10.00,"npi":[1841271459]}]}]}]},{"name":"Syst bp ge 130 - 139mm hg","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"3075F","description":"Syst bp ge 130 - 139mm hg","allowed_amounts":[{"tin":{"type":"ein","value":"923122837"},"service_code":["31"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1972818540]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":176.46,"providers":[{"billed_charge":815.00,"npi":[1396858999]}]},{"allowed_amount":272.96,"providers":[{"billed_charge":815.00,"npi":[1396858999]}]},{"allowed_amount":285.14,"providers":[{"billed_charge":815.00,"npi":[1396858999]}]},{"allowed_amount":679.00,"providers":[{"billed_charge":679.00,"npi":[1396858999]}]}]}]},{"name":"Ther\/proph\/diag inj sc\/im","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96372","description":"Ther\/proph\/diag inj sc\/im","allowed_amounts":[{"tin":{"type":"ein","value":"550492006"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":47.95,"providers":[{"billed_charge":48.00,"npi":[1902646615]}]}]}]},{"name":"Therapeutic Activities","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"97530GO","description":"Therapeutic Activities","allowed_amounts":[{"tin":{"type":"ein","value":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":79.76,"providers":[{"billed_charge":79.76,"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":"455513255"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":16.64,"providers":[{"billed_charge":16.64,"npi":[1992326730]}]}]}]},{"name":"Total cortisol","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82533","description":"Total cortisol","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":20.96,"providers":[{"billed_charge":102.90,"npi":[1063497451]}]}]}]},{"name":"Transvaginal us non-ob","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"76830","description":"Transvaginal us non-ob","allowed_amounts":[{"tin":{"type":"ein","value":"202935692"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":199.48,"providers":[{"billed_charge":374.00,"npi":[1568782563]}]}]}]},{"name":"Treponema pallidum","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86780","description":"Treponema pallidum","allowed_amounts":[{"tin":{"type":"ein","value":"550643304"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":26.60,"providers":[{"billed_charge":28.00,"npi":[1841271459]}]}]}]},{"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":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":81.72,"providers":[{"billed_charge":244.00,"npi":[1396858999]}]},{"allowed_amount":170.73,"providers":[{"billed_charge":488.00,"npi":[1396858999]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":4.07,"providers":[{"billed_charge":37.80,"npi":[1538144910]}]}]}]},{"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":"550643304"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":58.90,"providers":[{"billed_charge":62.00,"npi":[1841271459]}]}]}]},{"name":"Urine culture\/colony count","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87086","description":"Urine culture\/colony count","allowed_amounts":[{"tin":{"type":"ein","value":"010372148"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":86.00,"npi":[1396858999]}]}]}]},{"name":"Vitamin b-12","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82607","description":"Vitamin b-12","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":19.37,"providers":[{"billed_charge":111.30,"npi":[1063497451]}]}]}]},{"name":"Vitamin d 25 hydroxy","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82306","description":"Vitamin d 25 hydroxy","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":38.04,"providers":[{"billed_charge":243.60,"npi":[1538144910,1932184322]},{"billed_charge":286.65,"npi":[1063497451]}]}]}]},{"name":"Vitamin d 25 hydroxy","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"82306","description":"Vitamin d 25 hydroxy","allowed_amounts":[{"tin":{"type":"ein","value":"250965420"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":137.20,"providers":[{"billed_charge":343.00,"npi":[1952311508]}]}]}]},{"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":50.00,"providers":[{"billed_charge":50.00,"npi":[]}]}]}]}]}
