{"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 magnesium","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"83735","description":"Assay of magnesium","allowed_amounts":[{"tin":{"type":"ein","value":"586002491"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":32.25,"providers":[{"billed_charge":32.25,"npi":[1669488250]}]}]}]},{"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":"586002491"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":71.75,"providers":[{"billed_charge":71.75,"npi":[1669488250]}]}]}]},{"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":"586002491"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":69.70,"providers":[{"billed_charge":69.70,"npi":[1669488250]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":34.05,"providers":[{"billed_charge":160.02,"npi":[1063497451]}]}]}]},{"name":"Detect agnt mult dna ampli","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"87801","description":"Detect agnt mult dna ampli","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":90.22,"providers":[{"billed_charge":240.99,"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":"586002491"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":411.85,"providers":[{"billed_charge":411.85,"npi":[1669488250]}]}]}]},{"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":"472478680"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":267.23,"providers":[{"billed_charge":922.00,"npi":[1396727574]}]}]}]},{"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":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":"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":47.94,"providers":[{"billed_charge":152.88,"npi":[1063497451]}]}]}]},{"name":"Infec Agent Detection Be Nucleic Acid Amp. Probe Tech","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"8779859","description":"Infec Agent Detection Be Nucleic Acid Amp. Probe Tech","allowed_amounts":[{"tin":{"type":"ein","value":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":241.04,"npi":[1063497451]}]},{"allowed_amount":45.11,"providers":[{"billed_charge":120.52,"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]}]}]}]},{"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":24.57,"providers":[{"billed_charge":24.57,"npi":[1992326730]}]}]}]},{"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":"391351587"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":96.63,"providers":[{"billed_charge":263.00,"npi":[1295380053]}]}]}]},{"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":"223146927"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":121.84,"providers":[{"billed_charge":398.00,"npi":[1497875249]}]}]}]},{"name":"Office\/outpatient visit est","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99215","description":"Office\/outpatient visit est","allowed_amounts":[{"tin":{"type":"ein","value":"581330744"},"service_code":["11"],"billing_class":"professional","payments":[{"allowed_amount":372.19,"providers":[{"billed_charge":500.00,"npi":[1457303638]}]}]}]},{"name":"Pharmacy","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0250","description":"Pharmacy","allowed_amounts":[{"tin":{"type":"ein","value":"586002491"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":8.30,"providers":[{"billed_charge":8.30,"npi":[1669488250]}]}]}]},{"name":"Pharmacy - iv solutions","billing_code_type":"RC","billing_code_type_version":"2026","billing_code":"0258","description":"Pharmacy - iv solutions","allowed_amounts":[{"tin":{"type":"ein","value":"586002491"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":91.60,"npi":[1669488250]}]}]}]},{"name":"Routine venipuncture","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"36415","description":"Routine venipuncture","allowed_amounts":[{"tin":{"type":"ein","value":"586002491"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":21.85,"providers":[{"billed_charge":21.85,"npi":[1669488250]}]}]}]},{"name":"Subsequent hospital care","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99232","description":"Subsequent hospital care","allowed_amounts":[{"tin":{"type":"ein","value":"160743905"},"service_code":["51"],"billing_class":"professional","payments":[{"allowed_amount":96.48,"providers":[{"billed_charge":178.00,"npi":[1417522004]}]},{"allowed_amount":99.04,"providers":[{"billed_charge":186.90,"npi":[1417522004,1801842919]}]}]}]},{"name":"Subsequent hospital care","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99233","description":"Subsequent hospital care","allowed_amounts":[{"tin":{"type":"ein","value":"160743905"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":146.40,"providers":[{"billed_charge":269.85,"npi":[1295149797]}]}]}]},{"name":"Subsequent hospital care","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99233","description":"Subsequent hospital care","allowed_amounts":[{"tin":{"type":"ein","value":"222785804"},"service_code":["21"],"billing_class":"professional","payments":[{"allowed_amount":222.79,"providers":[{"billed_charge":1078.00,"npi":[1477314219,1669977377,1750570131]}]}]}]},{"name":"Ther\/proph\/diag iv inf addon","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"96366","description":"Ther\/proph\/diag iv inf addon","allowed_amounts":[{"tin":{"type":"ein","value":"586002491"},"service_code":[],"billing_class":"institutional","payments":[{"allowed_amount":144.00,"providers":[{"billed_charge":144.00,"npi":[1669488250]}]}]}]},{"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":67.30,"providers":[{"billed_charge":67.30,"npi":[1992326730]}]}]}]},{"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":"882159993"},"service_code":["20"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":0.00,"npi":[1881636926]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":2.89,"providers":[{"billed_charge":32.55,"npi":[1063497451]}]}]}]},{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":10.37,"providers":[{"billed_charge":75.60,"npi":[1063497451]}]}]}]}]}
