{"reporting_entity_name": "GHP_HMO","reporting_entity_type": "GHP_HMO","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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":7.44,"providers":[{"billed_charge":68.20,"npi":[1063497451]}]}]}]},{"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":"473549116"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":432.03,"providers":[{"billed_charge":950.00,"npi":[1528453628]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427RH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"232332158"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":511.50,"providers":[{"billed_charge":1442.00,"npi":[1649220500]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427RH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"246024144"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":513.04,"providers":[{"billed_charge":1400.00,"npi":[1891854840]}]},{"allowed_amount":1325.00,"providers":[{"billed_charge":1400.00,"npi":[1891854840]}]}]}]},{"name":"Ambulance Service,Advanced Life Support\/Emergency Level 1","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"A0427RH","description":"Ambulance Service,Advanced Life Support\/Emergency Level 1","allowed_amounts":[{"tin":{"type":"ein","value":"473549116"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":713.13,"providers":[{"billed_charge":1700.00,"npi":[1528453628]}]}]}]},{"name":"Antinuclear antibodies","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"86038","description":"Antinuclear antibodies","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":15.53,"providers":[{"billed_charge":105.00,"npi":[1063497451]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":8.36,"providers":[{"billed_charge":38.85,"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":80.97,"npi":[1063497451]}]}]}]},{"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":"240796250"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":67.95,"providers":[{"billed_charge":337.92,"npi":[1952351967]}]}]}]},{"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":[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 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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":6.65,"providers":[{"billed_charge":60.95,"npi":[1063497451]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":6.65,"providers":[{"billed_charge":84.00,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":32.55,"providers":[{"billed_charge":32.55,"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":"460750728"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":66.71,"providers":[{"billed_charge":249.00,"npi":[1528319621]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":13.60,"providers":[{"billed_charge":61.43,"npi":[1063497451]}]},{"allowed_amount":48.30,"providers":[{"billed_charge":48.30,"npi":[1063497451]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":72.48,"providers":[{"billed_charge":462.00,"npi":[1063497451]}]},{"allowed_amount":453.60,"providers":[{"billed_charge":453.60,"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":71.85,"providers":[{"billed_charge":317.10,"npi":[1063497451]}]},{"allowed_amount":214.20,"providers":[{"billed_charge":214.20,"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":"460750728"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":176.32,"providers":[{"billed_charge":658.14,"npi":[1528319621]}]}]}]},{"name":"Emergency Dept Visit","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"9928325","description":"Emergency Dept Visit","allowed_amounts":[{"tin":{"type":"ein","value":"460750728"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":307.24,"providers":[{"billed_charge":1146.85,"npi":[1528319621]}]}]}]},{"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":"240796250"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":662.99,"providers":[{"billed_charge":3297.22,"npi":[1952351967]}]}]}]},{"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":"240796250"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":205.20,"providers":[{"billed_charge":1087.71,"npi":[1023069457]}]}]}]},{"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":"465034266"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":325.16,"providers":[{"billed_charge":1324.00,"npi":[1962841130]}]}]}]},{"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":"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":"240796250"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":188.02,"providers":[{"billed_charge":935.10,"npi":[1952351967]}]}]}]},{"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":"232332158"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":50.50,"providers":[{"billed_charge":143.00,"npi":[1649220500]}]}]}]},{"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":"246024144"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":89.03,"providers":[{"billed_charge":165.00,"npi":[1891854840]}]},{"allowed_amount":118.95,"providers":[{"billed_charge":332.50,"npi":[1891854840]}]}]}]},{"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":"473549116"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":54.90,"providers":[{"billed_charge":120.00,"npi":[1528453628]}]},{"allowed_amount":89.03,"providers":[{"billed_charge":140.00,"npi":[1528453628]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":112.35,"providers":[{"billed_charge":112.35,"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":102.90,"npi":[1063497451]},{"billed_charge":116.02,"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":"460750728"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":164.22,"providers":[{"billed_charge":613.00,"npi":[1528319621]}]}]}]},{"name":"Nursing fac care subseq","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99309","description":"Nursing fac care subseq","allowed_amounts":[{"tin":{"type":"ein","value":"822271765"},"service_code":["31"],"billing_class":"professional","payments":[{"allowed_amount":80.56,"providers":[{"billed_charge":182.14,"npi":[1063974129]}]}]}]},{"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":"223892149"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":13.75,"providers":[{"billed_charge":25.00,"npi":[1770544348]}]}]}]},{"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":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"460750728"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":11.25,"providers":[{"billed_charge":42.00,"npi":[1528319621]}]}]}]},{"name":"Urinalysis auto w\/o scope","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"81003","description":"Urinalysis auto w\/o scope","allowed_amounts":[{"tin":{"type":"ein","value":"240796250"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":31.76,"providers":[{"billed_charge":157.94,"npi":[1952351967]}]}]}]},{"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":[1063497451]}]}]}]}]}
