{"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":"133757370"},"service_code":["81"],"billing_class":"professional","payments":[{"allowed_amount":7.44,"providers":[{"billed_charge":76.77,"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":"232012867"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":437.74,"providers":[{"billed_charge":1200.00,"npi":[1205995263]}]}]}]},{"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":"236283535"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":513.04,"providers":[{"billed_charge":1500.00,"npi":[1780625194]}]}]}]},{"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":69.18,"npi":[1063497451]}]}]}]},{"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":"272134141"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":217.36,"providers":[{"billed_charge":1581.00,"npi":[1578576484]}]}]}]},{"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":195.30,"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":74.55,"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":"232012867"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":391.86,"providers":[{"billed_charge":1176.00,"npi":[1205995263]}]}]}]},{"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":"236283535"},"service_code":["41"],"billing_class":"professional","payments":[{"allowed_amount":137.25,"providers":[{"billed_charge":315.00,"npi":[1780625194]}]}]}]},{"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":108.15,"npi":[1063497451]}]}]}]},{"name":"Med serv 10pm-8am 24 hr fac","billing_code_type":"CPT","billing_code_type_version":"2026","billing_code":"99053","description":"Med serv 10pm-8am 24 hr fac","allowed_amounts":[{"tin":{"type":"ein","value":"272134141"},"service_code":["23"],"billing_class":"professional","payments":[{"allowed_amount":0.00,"providers":[{"billed_charge":56.00,"npi":[1578576484]}]}]}]}]}