{"reporting_entity_name": "GQO_PPO","reporting_entity_type": "GQO_PPO","last_updated_on": "2026-10-07","version": "1.0.0","out_of_network":[{"name":"Breast tomosynthesis bi","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"77063","description":"Breast tomosynthesis bi","allowed_amounts":[{"tin":{"type":"ein","value":"275493321"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":141.92,"providers":[{"billed_charge":141.92,"npi":[1386313740]}]}]}]},{"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":"382084239"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":34.43,"providers":[{"billed_charge":131.73,"npi":[1932166386]}]}]}]},{"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":"845095889"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":188.21,"providers":[{"billed_charge":1342.00,"npi":[1215362363]}]}]}]},{"name":"Emergency dept visit","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99285","description":"Emergency dept visit","allowed_amounts":[{"tin":{"type":"ein","value":"223586664"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":659.72,"providers":[{"billed_charge":1728.00,"npi":[1497783419]}]}]}]},{"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":"382084239"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":45.41,"providers":[{"billed_charge":157.21,"npi":[1932166386]}]}]}]},{"name":"Mh partial hosp tx under 24h","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"H0035","description":"Mh partial hosp tx under 24h","allowed_amounts":[{"tin":{"type":"ein","value":"231740249"},"service_code":["52"],"billing_class":"professional","payments":[{"allowed_amount":29.87,"providers":[{"billed_charge":450.00,"npi":[1750315826]}]},{"allowed_amount":34.59,"providers":[{"billed_charge":450.00,"npi":[1750315826]}]}]}]},{"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":"262059029"},"service_code":["10"],"billing_class":"professional","payments":[{"allowed_amount":122.64,"providers":[{"billed_charge":284.00,"npi":[1275894743]}]}]}]},{"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":"861004041"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":113.17,"providers":[{"billed_charge":277.00,"npi":[1063668531]}]}]}]},{"name":"Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"77067","description":"Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed","allowed_amounts":[{"tin":{"type":"ein","value":"275493321"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":343.86,"providers":[{"billed_charge":343.86,"npi":[1386313740]}]}]}]},{"name":"Tobacco non-user","billing_code_type":"HCPCS","billing_code_type_version":"2026","billing_code":"1036F","description":"Tobacco non-user","allowed_amounts":[{"tin":{"type":"ein","value":"593214635"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1255875472]}]}]}]}]}
