Customer detail

OneGI

130
live contracts
27
cannot fire
22
calc types
6
SQL bodies
1
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment1,755
PercentOfFees293
MedicareMultipleProcedureAdjustment152
LesserOfAdjustment150
MedicareMultipleRadiologyAdjustment149
MedicareBilateralSurgeryAdjustment145
MidLevelProviderAdjustment145
ChargeLevelSqlAdjustment132
MedicareMultipleEndoscopyAdjustment88
MedicareAnesthesia68
FlatFee61
FlatPercentOfCharges51
MedicareDrug40
MedicareRVU37
MedicareDME37
MedicareLab37
SqlExpression14
MedicareASC10
CalculationBuilder6
MedicareMultipleSurgeryAdjustment2
MedicareMultipleTherapyAdjustment1
MultipleSurgeryAdjustment1

Contracts

Each is one fee logic. Base terms are first-match-wins; adjustments all apply, in order. Expand to see the terms.

AIG-Oscar-Commercial-Profee5 base · 18 adj
Oscar
Profee · Gastro One-AIG · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 80% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU ⚠︎ named “120% of Medicare RVU (Rad Carveout at 70%)” but configured at 100%
    • CodeRange 70000–79999 → 70%
    • CodeRange 80000–89999 → 80%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Charges-DDC-Profee1 base · 0 adj
Charges
Profee · Dayton Gastro - DDC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the DDC-Chargemaster-Profees fee schedule
Charges-Facility Fees1 base · 0 adj
Charges
Facility · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG, ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GAVA, GAVA-CSLC, GAVA-GAT, GCM-Skyline ASC-Jackson, GHP, LEG-CSLC, MAC-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Chargemaster-Facility-Fees fee schedule
Charges-Facility Fees-ChargeType1 base · 0 adj
Charges
Facility · GCM-Gastro One, GCM-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Chargemaster-Facility-Fees-ChargeType-Based fee schedule
Charges-GHS-Profee1 base · 0 adj
Charges
Profee · Dayton Gastro - GHS · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GHS-Chargemaster-Profees fee schedule
Charges-Profee1 base · 0 adj
Charges
Profee · Dayton Gastro, Dayton Gastro-GLG, ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GAVA, GAVA-CSLC, GAVA-GAT, GHP, LEG-CSLC, MAC-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Chargemaster-Profees fee schedule
Charges-Profee-ChargeType1 base · 0 adj
Charges
Profee · GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Chargemaster-Profees-ChargeType-Based fee schedule
DG-United Healthcare Medicare-Profee7 base · 20 adj
United Healthcare Medicare
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-02-22 → 2099-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 60% of Medicare lab (OH)
  3. 100% of Medicare drug
  4. 60% of Medicare DME (OH)
  5. 100% of Medicare RVU
    • CodeRange 99202–99499 → 100%
    • CodeRange 10021–40489 → 95%
    • CodeRange 70000–79999 → 70%
    • CodeRange 92920–93799 → 95%
    • CodeRange 97010–97799 → 95%
    • CodeRange 50000–69999 → 95%
    • CodeRange 40490–49999 → 95%
  6. 100% of Medicare anesthesia
  7. 25% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. modifier 52 present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Dayton Gastro - Cigna Profees5 base · 17 adj
Cigna Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG, ASC, Clinic, Home, Hospital · 2012-02-01 → 2016-05-21
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro - Humana HMOx-Profee5 base · 17 adj
Humana HMOx
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 90% of Medicare lab
  3. 100% of Medicare drug
  4. 70% of Medicare DME
  5. 135% of Medicare RVU ⚠︎ named “100% of Medicare RVU” but configured at 135%
    • ProcedureCategory Radiology → 100%
    • ProcedureCategory Evaluation & Management → 100%
    • CodeRange 88305–88305 → 90%
    • CodeRange 88312–88312 → 90%
    • CodeRange 88342–88342 → 100%
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro - Humana Medicare-Profee6 base · 20 adj
Humana Medicare
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare anesthesia
  3. 50% of Medicare lab
  4. 100% of Medicare drug
  5. 75% of Medicare DME
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 53 present → 29% of the running amount
  19. modifier 52 present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Dayton Gastro - UHC Commercial Profees6 base · 19 adj
United Healthcare Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-12-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. flat $0 — when NoncoverageStatus Noncovered is present
  3. 100% of the Dayton-UHC-Facility-Carveouts fee schedule — when FacilityType in ASC, Hospital
  4. 100% of the Dayton-UHC-Clinic-Carveouts fee schedule
  5. 100% of the Dayton-UHC-Profee-Clinic fee schedule — when FacilityType in Clinic
  6. 100% of the Dayton-UHC-Profee-Facility fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Aetna Commercial Profees 20244 base · 17 adj
Aetna Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-07-15 → 2025-07-14
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Ohio-Aetna-Carveouts fee schedule
  3. 120% of the Ohio-Aetna-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 145%
    • CodeRange 40490–49906 → 145%
    • CodeRange j1745–j3380 → 110%
    • CodeRange q5103–q5103 → 110%
    • ProcedureCategory Pathology & Laboratory → 110%
    • ProcedureCategory Radiology → 100%
    • ProcedureCategory J-Codes, Q-Codes → 100%
    • CodeRange 88305–88305 → 140%
    • CodeRange 88312–88313 → 140%
    • CodeRange 88341–88342 → 140%
  4. 120% of the Ohio-Aetna-Clinic-Profees fee schedule
    • ProcedureCategory Evaluation & Management → 145%
    • CodeRange 40490–49906 → 145%
    • CodeRange j1745–j3380 → 110%
    • CodeRange q5103–q5103 → 110%
    • ProcedureCategory Pathology & Laboratory → 110%
    • ProcedureCategory Radiology → 100%
    • ProcedureCategory J-Codes, Q-Codes → 100%
    • CodeRange 88305–88305 → 140%
    • CodeRange 88312–88313 → 140%
    • CodeRange 88341–88342 → 140%
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Aetna Commercial Profees 20253 base · 19 adj
Aetna Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2025-07-15 → 2099-12-31
Base terms — first match wins
  1. 124% of the Ohio-Aetna-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
    • CodeRange 99202–99215 → 149%
    • CodeRange 99221–99380 → 149%
    • CodeRange 99473–99476 → 149%
    • CodeRange 99483–99498 → 149%
    • CodeRange 40490–49906 → 149%
    • CodeRange J1745–J3380 → 114%
    • CodeRange Q5103–Q5103 → 114%
    • CodeRange 88305–88305 → 144%
    • CodeRange 88312–88313 → 144%
    • CodeRange 88341–88342 → 144%
    • CodeRange 70010–79999 → 104%
    • CodeRange C8900–C8914 → 104%
    • CodeRange C8918–C8920 → 104%
    • CodeRange J0120–J1744 → 105%
    • CodeRange J3385–J9999 → 105%
    • CodeRange 80047–88304 → 110%
    • CodeRange 88307–88311 → 110%
    • CodeRange 88314–88334 → 110%
    • CodeRange 88344–89398 → 110%
  2. 124% of the Ohio-Aetna-Clinic-Profees fee schedule — when FacilityType in Clinic
    • CodeRange 99202–99215 → 149%
    • CodeRange 99221–99380 → 149%
    • CodeRange 99473–99476 → 149%
    • CodeRange 99483–99498 → 149%
    • CodeRange 40490–49906 → 149%
    • CodeRange J1745–J3380 → 114%
    • CodeRange Q5103–Q5103 → 114%
    • CodeRange 88305–88305 → 144%
    • CodeRange 88312–88313 → 144%
    • CodeRange 88341–88342 → 144%
    • CodeRange 70010–79999 → 104%
    • CodeRange C8900–C8914 → 104%
    • CodeRange C8918–C8920 → 104%
    • CodeRange J0120–J1744 → 105%
    • CodeRange J3385–J9999 → 105%
    • CodeRange 80047–88304 → 110%
    • CodeRange 88307–88311 → 110%
    • CodeRange 88314–88334 → 110%
    • CodeRange 88344–89398 → 110%
  3. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Aetna Medicare-Profee6 base · 18 adj
Aetna Medicare
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-07-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare anesthesia
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Anthem Commercial-Profee5 base · 17 adj
Anthem Commercial Plans
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $200 — when CodeRange in 00100–01999
  2. 100% of the Dayton-Anthem-Comm-Carveout-POS24-Profee fee schedule
  3. 100% of the GLG-Anthem-Commercial-Facility-Profee-Fee-2024 fee schedule — when FacilityType in ASC, Home, Hospital
  4. 100% of the GLG-Anthem-Commercial-NonFacility-Profee-Fee-2024 fee schedule — when FacilityType in Clinic
  5. 100% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Anthem Medicare-Profee6 base · 19 adj
Anthem Medicare Plans
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare anesthesia
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier 52 present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Dayton Gastro-AultCare-20256 base · 18 adj
AULTCARE
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2025-06-01 → 2026-05-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 70% of Medicare lab (OH, rates as of 2025-01-01)
  3. 100% of Medicare drug (rates as of 2025-01-01)
  4. 100% of Medicare DME (OH, rates as of 2025-01-01)
  5. 100% of Medicare RVU (rates as of 2025-01-01)
    • CodeRange 99216–99499 → 110%
    • CodeRange 99200–99215 → 100%
    • CodeRange 90750–96999 → 100%
    • ProcedureCategory Surgery → 113%
    • ProcedureCategory Radiology → 118%
    • CodeRange 80000–88304 → 70%
    • CodeRange 88306–89999 → 70%
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Dayton Gastro-AultCare-20266 base · 18 adj
AULTCARE
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2026-06-01 → 2099-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 70% of Medicare lab (OH)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (OH)
  5. 100% of Medicare RVU
    • CodeRange 99216–99499 → 110%
    • CodeRange 99200–99215 → 100%
    • CodeRange 90750–96999 → 90%
    • ProcedureCategory Surgery → 119%
    • ProcedureCategory Radiology → 116%
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Cigna Commercial-Profee-20245 base · 20 adj
Cigna Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-07-01 → 2025-07-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. custom SQL — Cigna Commercial anesthesia-CPT-range (00100-01999) profee schedule lookup, facility-vs-clinic aware, returned as a flat per-line amount with units intentionally ignored.
  3. 100% of the GLG-Cigna Commercial-Facility-Profee-Fee-2024 fee schedule — when FacilityType in ASC, Home, Hospital
  4. 100% of the GLG-Cigna Commercial-NonFacility-Profee-Fee-2024 fee schedule — when FacilityType in Clinic
  5. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. modifier QZ present → 85% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Cigna Commercial-Profee-20255 base · 20 adj
Cigna Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2025-08-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the Dayton-Cigna-Drugs-Profee fee schedule
  2. 100% of Medicare anesthesia
  3. 100% of the GLG-Cigna Commercial-Facility-Profee-Fee-2024 fee schedule — when FacilityType in ASC, Home, Hospital
  4. 100% of the GLG-Cigna Commercial-NonFacility-Profee-Fee-2024 fee schedule — when FacilityType in Clinic
  5. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. modifier QZ present → 85% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Humana Commercial-Profee5 base · 17 adj
Humana Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2023-07-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 70% of Medicare DME
  5. 150% of Medicare RVU ⚠︎ named “100% of Medicare RVU” but configured at 150%
    • ProcedureCategory Radiology → 100%
    • ProcedureCategory Evaluation & Management → 133.5%
    • CodeRange 88305–88305 → 100%
    • CodeRange 88312–88312 → 100%
    • CodeRange 88342–88342 → 100%
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Humana Commercial-Profee-20253 base · 17 adj
Humana Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Dayton-Humana-Profee-Clinic fee schedule — when FacilityType in Clinic
  3. 100% of the Dayton-Humana-Profee-Facility fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Medical Mutual Comm-Profee-2024/255 base · 18 adj
Medical Mutual Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2024-01-01 → 2026-01-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare anesthesia
  3. 101.18% of the Dayton-MMO-Commercial-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital
    • CodeRange 43020–49999 → 175%
    • CodeRange 91010–91299 → 175%
    • CodeRange 99201–99499 → 150%
    • CodeRange 88000–89398 → 130%
  4. 101.18% of the Dayton-MMO-Commercial-NonFacility-Profee fee schedule
    • CodeRange 43020–49999 → 175%
    • CodeRange 91010–91299 → 175%
    • CodeRange 99201–99499 → 150%
    • CodeRange 88000–89398 → 130%
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 14% of the running amount
  13. modifier QY present → 50% of the running amount
  14. modifier QK present → 50% of the running amount
  15. modifier QX present → 50% of the running amount
  16. modifier 53 present → 50% of the running amount
  17. modifier 52 present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Medical Mutual Comm-Profee-20265 base · 17 adj
Medical Mutual Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG, LEG-CSLC · 2026-02-01 → 2027-01-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare anesthesia
  3. 100% of the Dayton-MMO-Commercial-Facility-Profee fee schedule — when FacilityType in ASC, Home, Hospital
  4. 100% of the Dayton-MMO-Commercial-NonFacility-Profee fee schedule
  5. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Medical Mutual Comm-Profee-20276 base · 17 adj
Medical Mutual Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2027-02-01 → 2028-01-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
    • CodeRange 88000–89398 → 133%
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
    • CodeRange 99201–99499 → 149%
    • CodeRange 88000–89398 → 133%
    • CodeRange 43020–49999 → 186%
    • CodeRange 91010–91299 → 186%
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro-Medical Mutual Comm-Profee-20286 base · 17 adj
Medical Mutual Commercial
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2028-02-01 → 2099-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
    • CodeRange 88000–89398 → 135%
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
    • CodeRange 99201–99499 → 152%
    • CodeRange 88000–89398 → 135%
    • CodeRange 43020–49999 → 193%
    • CodeRange 91010–91299 → 193%
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton-Gastro-Summa Health-Profee6 base · 18 adj
SummaCare
Profee · Dayton Gastro, Dayton Gastro-GLG, Dayton Gastro - DDC, Dayton Gastro - GHS · 2024-04-30 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 160% of Medicare RVU
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Dayton-Gastro-Summa Health-Profee6 base · 18 adj
Ambetter, Centene
Profee · Dayton Gastro, Dayton Gastro-GLG, Dayton Gastro - DDC, Dayton Gastro - GHS · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 133% of Medicare lab
  3. 133% of Medicare drug
  4. 133% of Medicare DME
  5. 133% of Medicare RVU
  6. 133% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
DaytonGastro-CareSource-Profee6 base · 18 adj
Caresource, Caresource Medicare
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
ECNM-Aetna Commercial-Facility3 base · 17 adj
Aetna Commercial
Facility · ECNM-GANM · 2025-01-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the ECNM-Aetna Commercial-NonCovered-Fees fee schedule
  2. 100% of the ECNM-Aetna Commercial-Facility-Fees-2025 fee schedule
  3. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
ECNM-Aetna Medicare-Facility2 base · 18 adj
Aetna Medicare
Facility · ECNM-GANM · 2026-05-21 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
ECNM-Ambetter-ASC-Facility2 base · 18 adj
Ambetter, Centene
Facility · ECNM-GANM · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 155% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
ECNM-BCBS MS-Facility1 base · 18 adj
Anthem/BCBS Mississippi Commercial
Facility · ECNM-GANM · 2024-05-24 → 2999-12-31
Base terms — first match wins
  1. 100% of the ECNM-BCBS MS-Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
ECNM-Cigna Commercial-Facility1 base · 18 adj
Cigna Commercial
Facility · ECNM-GANM · 2015-04-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the ECNM-Cigna Commercial-Facility-Fees fee schedule
    • CodeRange 275–278 → 0%
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/0/0/0%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
ECNM-United Healthcare Commercial-Facility1 base · 18 adj
United Healthcare Commercial
Facility · ECNM-GANM · 2022-07-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the ECNM-United Healthcare Commercial-Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/0/0/0%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
ECNM-United Healthcare Medicare-Facility1 base · 18 adj
United Healthcare Medicare
Facility · ECNM-GANM · 2022-07-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the ECNM-United Healthcare Medicare-Facility-Fee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/0/0/0%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
FL-UHC-Profee6 base · 18 adj
United Healthcare Commercial
Professional · FL · 2025-08-15 → 2999-12-31
Base terms — first match wins
  1. 45% of Medicare lab (rates as of 2020-01-01)
  2. 100% of Medicare drug
    • CodeRange 96401–96549 → 106%
  3. 60% of Medicare DME (rates as of 2020-01-01)
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 70010–79999 → 80%
    • CodeRange 97000–97799 → 70%
    • CodeRange 90460–90474 → 85%
  6. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA - Aetna Commercial Profees7 base · 18 adj
Aetna Commercial
Profee · GAVA, GAVA-CSLC, GAVA-GAT · 2024-01-01 → 2025-07-31
Base terms — first match wins
  1. 100% of the GAVA-Aetna-Facility-Carveouts fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GAVA-Aetna-Clinic-Carveouts fee schedule
  3. 100% of Medicare anesthesia
  4. 125% of the GAVA-Aetna-NV-Facility-Profees fee schedule — when VARegion NV is present; FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 141%
    • ProcedureCategory Surgery → 142%
    • ProcedureCategory Pathology & Laboratory → 130%
    • CodeRange 96365–96365 → 138%
    • CodeRange 96413–96415 → 138%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 100%
  5. 125% of the GAVA-Aetna-NV-Clinic-Profees fee schedule — when VARegion NV is present
    • ProcedureCategory Evaluation & Management → 141%
    • ProcedureCategory Surgery → 142%
    • ProcedureCategory Pathology & Laboratory → 130%
    • CodeRange 96365–96365 → 138%
    • CodeRange 96413–96415 → 138%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 100%
  6. 125% of the GAVA-Aetna-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 141%
    • ProcedureCategory Surgery → 142%
    • ProcedureCategory Pathology & Laboratory → 130%
    • CodeRange 96365–96365 → 138%
    • CodeRange 96413–96415 → 138%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 100%
  7. 125% of the GAVA-Aetna-TideW-Clinic-Profees fee schedule — when VARegion TW is present
    • ProcedureCategory Evaluation & Management → 141%
    • ProcedureCategory Surgery → 142%
    • ProcedureCategory Pathology & Laboratory → 130%
    • CodeRange 96365–96365 → 138%
    • CodeRange 96413–96415 → 138%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 100%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. mid-level provider reduction (by NUCC taxonomy)
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA - Aetna Medicare Profees5 base · 18 adj
Aetna Medicare
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the GAVA-Aetna-NV-Facility-Profees fee schedule — when VARegion NV is present; FacilityType in ASC, Home, Hospital
  3. 100% of the GAVA-Aetna-NV-Clinic-Profees fee schedule — when VARegion NV is present
  4. 100% of the GAVA-Aetna-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  5. 100% of the GAVA-Aetna-TideW-Clinic-Profees fee schedule — when VARegion TW is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA - Aetna Profee - 20257 base · 19 adj
Aetna Commercial
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2025-08-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GAVA-Aetna-Facility-Carveouts fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GAVA-Aetna-Clinic-Carveouts fee schedule — when FacilityType in Clinic
  3. 100% of Medicare anesthesia
  4. 128% of the GAVA-Aetna-NV-Facility-Profees fee schedule — when VARegion NV is present; FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 146.25%
    • ProcedureCategory Surgery → 146%
    • ProcedureCategory Pathology & Laboratory → 135%
    • CodeRange 96365–96365 → 142%
    • CodeRange 96413–96415 → 143.25%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 135%
  5. 128% of the GAVA-Aetna-NV-Clinic-Profees fee schedule — when VARegion NV is present
    • ProcedureCategory Evaluation & Management → 146.25%
    • ProcedureCategory Surgery → 146%
    • ProcedureCategory Pathology & Laboratory → 135%
    • CodeRange 96365–96365 → 142%
    • CodeRange 96413–96415 → 143.25%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 135%
  6. 128% of the GAVA-Aetna-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 146.25%
    • ProcedureCategory Surgery → 146%
    • ProcedureCategory Pathology & Laboratory → 135%
    • CodeRange 96365–96365 → 142%
    • CodeRange 96413–96415 → 143.25%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 135%
  7. 128% of the GAVA-Aetna-TideW-Clinic-Profees fee schedule — when VARegion TW is present
    • ProcedureCategory Evaluation & Management → 146.25%
    • ProcedureCategory Surgery → 146%
    • ProcedureCategory Pathology & Laboratory → 135%
    • CodeRange 96365–96365 → 142%
    • CodeRange 96413–96415 → 143.25%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 135%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. mid-level provider reduction (by NUCC taxonomy)
  5. Medicare multiple-procedure reduction — base codes 3; pays 100/50/50/50/50/50%
  6. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25% — when Modifier 55 is absent
  7. modifier 22 present → 135% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA - United Healthcare Commercial Profees6 base · 19 adj
UMR, United Healthcare Commercial
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GAVA-UHC-Facility-Profees-Midlevel fee schedule — when FacilityType in ASC, Hospital; ProviderType in Mid-Level Provider, Nurse Practitioner, Physician Assistant
  2. 100% of the GAVA-UHC-Clinic-Profees-Midlevel fee schedule — when ProviderType in Mid-Level Provider, Nurse Practitioner, Physician Assistant
  3. 100% of the GAVA-UHC-Facility-Profees fee schedule — when FacilityType in ASC, Hospital
  4. 100% of the GAVA-UHC-Clinic-Profees fee schedule
  5. 100% of Medicare anesthesia
  6. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier 52 present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA - United Healthcare Options Profees6 base · 19 adj
United Healthcare Options PPO
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GAVA-UHC-Facility-Profees-Midlevel fee schedule — when PhysicianVsNonPhysician Midlevel is present; FacilityType in ASC, Hospital
  2. 100% of the GAVA-UHC-Clinic-Profees-Midlevel fee schedule — when PhysicianVsNonPhysician Midlevel is present
  3. 100% of the GAVA-UHC-Facility-Profees fee schedule — when FacilityType in ASC, Hospital
  4. 100% of the GAVA-UHC-Clinic-Profees fee schedule
  5. 100% of Medicare anesthesia
  6. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA-Anthem Commercial-Profee (2025)8 base · 19 adj
Anthem Blue Traditional, Anthem Commercial Plans
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2025-03-01 → 2026-02-28
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 109.71% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 109.71% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when FacilityType in Clinic; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  5. 109.71% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 109.71% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 109.71% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Hospital, Home
  8. 109.71% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/25/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% of the running amount
  6. modifier 53 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. modifier 55 present → 20% of the running amount
  9. modifier 56 present → 10% of the running amount
  10. modifier 62 present → 63% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA-Anthem Commercial-Profee (2026)8 base · 16 adj
Anthem Commercial Plans
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2026-03-01 → 2027-02-28
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 114.65% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 114.65% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth; FacilityType in Clinic
  5. 114.65% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 114.65% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 114.65% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  8. 114.65% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/25/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% of the running amount
  6. modifier 53 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. modifier 55 present → 20% of the running amount
  9. modifier 56 present → 10% of the running amount
  10. modifier 62 present → 63% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. cap each charge and the account total at 100% of billed charges
GAVA-Anthem Commercial-Profee (2027)8 base · 16 adj
Anthem Commercial Plans
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2027-03-01 → 2028-02-29
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 120.38% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 120.38% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth; FacilityType in ASC, Home, Hospital
  5. 120.38% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 120.38% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 120.38% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  8. 120.38% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/25/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% of the running amount
  6. modifier 53 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. modifier 55 present → 20% of the running amount
  9. modifier 56 present → 10% of the running amount
  10. modifier 62 present → 63% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. cap each charge and the account total at 100% of billed charges
GAVA-Anthem HMO-Profee (2025)8 base · 20 adj
Anthem HMO
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2025-03-01 → 2026-02-28
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 98.5% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 98.5% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth; FacilityType in ASC, Home, Hospital; Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  5. 105.92% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 105.92% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 98.85% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  8. 98.85% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GAVA-Anthem HMO-Profee (2026)8 base · 20 adj
Anthem HMO
Profee · GAVA, LEG-CSLC · 2026-03-01 → 2027-02-28
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 110.69% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 110.69% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth; FacilityType in Clinic
  5. 110.69% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 110.69% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 103.3% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  8. 103.3% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GAVA-Anthem HMO-Profee (2027)8 base · 20 adj
Anthem HMO
Profee · GAVA, LEG-CSLC · 2027-03-01 → 2028-02-28
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 116.22% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 116.22% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth; FacilityType in Clinic
  5. 116.22% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 116.22% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 108.47% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  8. 108.47% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GAVA-Anthem Medicare-Profee6 base · 18 adj
Anthem Medicare Plans
Profee · GAVA, ASC, Clinic, Home, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare anesthesia
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA-Anthem Pathway-Profee (2025)8 base · 20 adj
Anthem Pathway HMO
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2025-03-01 → 2026-02-28
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 87.07% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 87.07% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth; FacilityType in Clinic
  5. 87.07% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 87.07% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 81.78% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  8. 81.78% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GAVA-Anthem Pathway-Profee (2026)8 base · 20 adj
Anthem Pathway HMO
Profee · GAVA, LEG-CSLC · 2026-03-01 → 2027-02-28
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 90.99% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 90.99% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth; FacilityType in Clinic
  5. 90.99% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 90.99% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 85.46% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  8. 85.46% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GAVA-Anthem Pathway-Profee (2027)8 base · 20 adj
Anthem Pathway HMO
Profee · GAVA, LEG-CSLC · 2027-03-01 → 2028-02-28
Base terms — first match wins
  1. 100% of the GAVA-Anthem-Warrenton-Anes-Carveouts fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  2. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}. — when Facility not in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  3. 95.54% of the GAVA-Anthem-Warrenton-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital; Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth
  4. 95.54% of the GAVA-Anthem-Warrenton-Clinic-Profees fee schedule — when Facility in Warrenton Endo-GAPC, Warrenton-GAPC, Warrenton-Telehealth; FacilityType in Clinic
  5. 95.54% of the GAVA-Anthem-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
  6. 95.54% of the GAVA-Anthem-TideW-Clinic-Profees fee schedule — when VARegion TW is present
  7. 89.73% of the GAVA-Anthem-NV-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  8. 89.73% of the GAVA-Anthem-NV-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GAVA-CareFirst-HMO-Profee4 base · 19 adj
CareFirst HMO
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC, ASC, Clinic, Home, Hospital · 2024-02-19 → 2999-12-31
Base terms — first match wins
  1. 100% of the GAVA-CareFirst-HMO-ASC-Profee fee schedule — when PropertyTypeRule in 24
  2. 100% of the GAVA-CareFirst-HMO-Facility-Profee fee schedule — when FacilityType in Home, Hospital
  3. 100% of the GAVA-CareFirst-HMO-NonFacility-Profee fee schedule — when FacilityType in Clinic
  4. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% of the running amount
  6. modifier 53 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. modifier 55 present → 20% of the running amount
  9. modifier 56 present → 10% of the running amount
  10. modifier 62 present → 63% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA-CareFirst-PPO-Profee4 base · 19 adj
CareFirst PPO
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC, ASC, Clinic, Home, Hospital · 2024-02-19 → 2999-12-31
Base terms — first match wins
  1. 100% of the GAVA-CareFirst-ASC-Profee fee schedule — when FacilityType in ASC
  2. 100% of the GAVA-CareFirst-Facility-Profee fee schedule — when FacilityType in Home, Hospital
  3. 100% of the GAVA-CareFirst-NonFacility-Profee fee schedule — when FacilityType in Clinic
  4. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 120% of the running amount
  6. modifier 53 present → 50% of the running amount
  7. modifier 54 present → 70% of the running amount
  8. modifier 55 present → 20% of the running amount
  9. modifier 56 present → 10% of the running amount
  10. modifier 62 present → 63% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA-Cigna Commercial-CSLC-Profee-20254 base · 17 adj
Cigna Commercial
Profee · GAVA-CSLC, LEG-CSLC, MAC-CSLC · 2023-01-01 → 2024-12-31
Base terms — first match wins
  1. 100% of the GAVA-Cigna-CSLC-Hospital-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GAVA-Cigna-CSLC-Clinic-Profees fee schedule — when FacilityType in Clinic
  3. 100% of Medicare drug
  4. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode S0285 is absent
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
GAVA-Cigna Commercial-GAT-Profee-20253 base · 17 adj
Cigna Commercial
Profee · GAVA, GAVA-GAT · 2023-01-01 → 2024-12-31
Base terms — first match wins
  1. 100% of the GAVA-Cigna-GAT-Clinic-Profees fee schedule
  2. 100% of Medicare drug
  3. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode S0285 is absent
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
GAVA-Cigna-GAPC-Profee4 base · 18 adj
Cigna Commercial
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2025-01-01 → 2026-01-14
Base terms — first match wins
  1. 100% of the GAVA-Cigna-GAPC-Profee-Hospital fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GAVA-Cigna-GAPC-Profee-Clinic fee schedule — when FacilityType in Clinic
  3. 100% of Medicare anesthesia
  4. 60% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode S0285 is absent
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA-Cigna-GAPC-Profee-20264 base · 19 adj
Cigna Commercial
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2026-01-15 → 2099-12-31
Base terms — first match wins
  1. 100% of the GAVA-Cigna-GAPC-Profee-Hospital fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GAVA-Cigna-GAPC-Profee-Clinic fee schedule — when FacilityType in Clinic
  3. 100% of Medicare anesthesia
  4. 75% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode S0285 is absent
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier 53 present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA-HealthKeepers-GAPC-Profee2 base · 17 adj
HealthKeepers
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2024-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the GAPC-HealthKeepers-Profee-Facility fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GAPC-HealthKeepers-Profee-Clinic fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode S0285 is absent
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
GAVA-Humana Medicare-Clinic-Profee4 base · 17 adj
Humana Medicare
Profee · GAVA, GAVA-CSLC, GAVA-GAT, Clinic · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. 100% of the GAVA-Humana Medicare-201_580-Profee fee schedule — when VARegion NV is present
  2. 100% of the GAVA-Humana Medicare-201_544-Profee fee schedule
  3. 112% of the GAVA-Humana Medicare-005_220-Profee-Clinic fee schedule — when VARegion TW is present
    • CodeRange 80047–89398 → 50%
    • CodeRange A4206–V5299 → 75%
    • CodeRange 97001–98943 → 80%
    • CodeRange A9579–A9579 → 85%
    • CodeRange C8900–C8920 → 85%
    • CodeRange G0030–G0047 → 85%
    • CodeRange G0106–G0106 → 85%
    • CodeRange G0120–G0130 → 85%
    • CodeRange G0202–G0236 → 85%
    • CodeRange G0252–G0255 → 85%
    • CodeRange G0262–G0262 → 85%
    • CodeRange G0275–G0278 → 85%
    • CodeRange G0288–G0288 → 85%
    • CodeRange G0296–G0296 → 85%
    • CodeRange G0202–G0340 → 85%
    • CodeRange G0389–G0389 → 85%
    • CodeRange R0070–R0076 → 85%
    • CodeRange S0345–S0347 → 85%
    • CodeRange S0820–S0830 → 85%
    • CodeRange S8080–S8092 → 85%
    • CodeRange S9022–S9025 → 85%
    • CodeRange S8055–S8055 → 85%
  4. 100% of the GAVA-Humana Medicare-005_220-Profee-Clinic fee schedule — when VARegion NV is present
    • CodeRange 80047–89398 → 50%
    • CodeRange A4206–V5299 → 75%
    • CodeRange 97001–98943 → 80%
    • CodeRange A9579–A9579 → 85%
    • CodeRange C8900–C8920 → 85%
    • CodeRange G0030–G0047 → 85%
    • CodeRange G0106–G0106 → 85%
    • CodeRange G0120–G0130 → 85%
    • CodeRange G0202–G0236 → 85%
    • CodeRange G0252–G0255 → 85%
    • CodeRange G0262–G0262 → 85%
    • CodeRange G0275–G0278 → 85%
    • CodeRange G0288–G0288 → 85%
    • CodeRange G0296–G0296 → 85%
    • CodeRange G0202–G0340 → 85%
    • CodeRange G0389–G0389 → 85%
    • CodeRange R0070–R0076 → 85%
    • CodeRange S0345–S0347 → 85%
    • CodeRange S0820–S0830 → 85%
    • CodeRange S8080–S8092 → 85%
    • CodeRange S9022–S9025 → 85%
    • CodeRange S8055–S8055 → 85%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. cap each charge and the account total at 100% of billed charges
GAVA-Humana Medicare-Clinic-Profee4 base · 19 adj
Humana Medicare
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC, Clinic · 2025-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the GAVA-Humana Medicare-201_580-Profee fee schedule — when VARegion NV is present
  2. 100% of the GAVA-Humana Medicare-201_544-Profee fee schedule
  3. 112% of the GAVA-Humana Medicare-005_220-Profee-Clinic fee schedule — when VARegion TW is present
    • CodeRange 80047–89398 → 50%
    • CodeRange A4206–V5299 → 75%
    • CodeRange 97001–98943 → 80%
    • CodeRange A9579–A9579 → 85%
    • CodeRange C8900–C8920 → 85%
    • CodeRange G0030–G0047 → 85%
    • CodeRange G0106–G0106 → 85%
    • CodeRange G0120–G0130 → 85%
    • CodeRange G0202–G0236 → 85%
    • CodeRange G0252–G0255 → 85%
    • CodeRange G0262–G0262 → 85%
    • CodeRange G0275–G0278 → 85%
    • CodeRange G0288–G0288 → 85%
    • CodeRange G0296–G0296 → 85%
    • CodeRange G0202–G0340 → 85%
    • CodeRange G0389–G0389 → 85%
    • CodeRange R0070–R0076 → 85%
    • CodeRange S0345–S0347 → 85%
    • CodeRange S0820–S0830 → 85%
    • CodeRange S8080–S8092 → 85%
    • CodeRange S9022–S9025 → 85%
    • CodeRange S8055–S8055 → 85%
  4. 100% of the GAVA-Humana Medicare-005_220-Profee-Clinic fee schedule — when VARegion NV is present
    • CodeRange 80047–89398 → 50%
    • CodeRange A4206–V5299 → 75%
    • CodeRange 97001–98943 → 80%
    • CodeRange A9579–A9579 → 85%
    • CodeRange C8900–C8920 → 85%
    • CodeRange G0030–G0047 → 85%
    • CodeRange G0106–G0106 → 85%
    • CodeRange G0120–G0130 → 85%
    • CodeRange G0202–G0236 → 85%
    • CodeRange G0252–G0255 → 85%
    • CodeRange G0262–G0262 → 85%
    • CodeRange G0275–G0278 → 85%
    • CodeRange G0288–G0288 → 85%
    • CodeRange G0296–G0296 → 85%
    • CodeRange G0202–G0340 → 85%
    • CodeRange G0389–G0389 → 85%
    • CodeRange R0070–R0076 → 85%
    • CodeRange S0345–S0347 → 85%
    • CodeRange S0820–S0830 → 85%
    • CodeRange S8080–S8092 → 85%
    • CodeRange S9022–S9025 → 85%
    • CodeRange S8055–S8055 → 85%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier 52 present → 50% of the running amount
  18. modifier 53 present → 15% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA-Humana Medicare-Facility-Profee4 base · 17 adj
Humana Medicare
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC, ASC, Hospital · 2025-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the GAVA-Humana Medicare-201_580-Profee fee schedule — when VARegion NV is present
  2. 100% of the GAVA-Humana Medicare-201_544-Profee fee schedule
  3. 112% of the GAVA-Humana Medicare-005_220-Profee-Facility fee schedule — when VARegion TW is present
    • CodeRange 80047–89398 → 50%
    • CodeRange A4206–V5299 → 75%
    • CodeRange 97001–98943 → 80%
    • CodeRange A9579–A9579 → 85%
    • CodeRange C8900–C8920 → 85%
    • CodeRange G0030–G0047 → 85%
    • CodeRange G0106–G0106 → 85%
    • CodeRange G0120–G0130 → 85%
    • CodeRange G0202–G0236 → 85%
    • CodeRange G0252–G0255 → 85%
    • CodeRange G0262–G0262 → 85%
    • CodeRange G0275–G0278 → 85%
    • CodeRange G0288–G0288 → 85%
    • CodeRange G0296–G0296 → 85%
    • CodeRange G0202–G0340 → 85%
    • CodeRange G0389–G0389 → 85%
    • CodeRange R0070–R0076 → 85%
    • CodeRange S0345–S0347 → 85%
    • CodeRange S0820–S0830 → 85%
    • CodeRange S8080–S8092 → 85%
    • CodeRange S9022–S9025 → 85%
    • CodeRange S8055–S8055 → 85%
  4. 100% of the GAVA-Humana Medicare-005_220-Profee-Facility fee schedule — when VARegion NV is present
    • CodeRange 80047–89398 → 50%
    • CodeRange A4206–V5299 → 75%
    • CodeRange 97001–98943 → 80%
    • CodeRange A9579–A9579 → 85%
    • CodeRange C8900–C8920 → 85%
    • CodeRange G0030–G0047 → 85%
    • CodeRange G0106–G0106 → 85%
    • CodeRange G0120–G0130 → 85%
    • CodeRange G0202–G0236 → 85%
    • CodeRange G0252–G0255 → 85%
    • CodeRange G0262–G0262 → 85%
    • CodeRange G0275–G0278 → 85%
    • CodeRange G0288–G0288 → 85%
    • CodeRange G0296–G0296 → 85%
    • CodeRange G0202–G0340 → 85%
    • CodeRange G0389–G0389 → 85%
    • CodeRange R0070–R0076 → 85%
    • CodeRange S0345–S0347 → 85%
    • CodeRange S0820–S0830 → 85%
    • CodeRange S8080–S8092 → 85%
    • CodeRange S9022–S9025 → 85%
    • CodeRange S8055–S8055 → 85%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. cap each charge and the account total at 100% of billed charges
GAVA-LEG-CareFirst-ASC-Facility2 base · 17 adj
CareFirst HMO, CareFirst PPO
Facility · ASC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GAVA-LEG-CareFirst-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
GAVA-Multiplan-GAPC-Profee3 base · 17 adj
MultiPlan
Profee · GAVA · 2024-01-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the GAVA-Multiplan-Hospital-Profee fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GAVA-Multiplan-Clinic-Profee fee schedule — when FacilityType in Clinic
  3. 55% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode S0285 is absent
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
GAVA-Sentara Commercial-Profee - 20253 base · 18 adj
Sentara Commercial
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2025-01-01 → 2025-12-31
Base terms — first match wins
  1. 189% of the GAVA-Sentara Commercial-NonFacility-Profee-Fee - 2025 fee schedule — when FacilityType in ASC, Home, Hospital
  2. 189% of the GAVA-Sentara Commercial-Facility-Profee-Fee - 2025 fee schedule
  3. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA-Sentara Commercial-Profee - 20263 base · 18 adj
Sentara Commercial
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2026-01-01 → 2026-12-31
Base terms — first match wins
  1. 194% of the GAVA-Sentara Commercial-NonFacility-Profee-Fee - 2025 fee schedule — when FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 194%
  2. 194% of the GAVA-Sentara Commercial-Facility-Profee-Fee - 2025 fee schedule — when FacilityType in Clinic
    • ProcedureCategory Evaluation & Management → 194%
  3. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA-Sentara Commercial-Profee - 20273 base · 18 adj
Sentara Commercial
Profee · GAVA, GAVA-CSLC, GAVA-GAT, LEG-CSLC · 2027-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GAVA-Sentara Commercial-Facility-Profee-Fee - 2025 fee schedule — when FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 199%
  2. 100% of the GAVA-Sentara Commercial-NonFacility-Profee-Fee - 2025 fee schedule — when FacilityType in Clinic
    • ProcedureCategory Evaluation & Management → 199%
  3. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA-Sentara Medicare-Profee2 base · 18 adj
Sentara Medicare
Profee · LEG-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-AARP-TN-Profees4 base · 17 adj
AARP
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, TN · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the GCM-AARP-TN-Hospital-Profees fee schedule — when FacilityState in TN; FacilityType in ASC, Hospital
  3. 100% of the GCM-AARP-TN-Clinic-Profees fee schedule — when FacilityState in TN
  4. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
GCM-Aetna Commercial Profees12 base · 19 adj
Aetna Commercial
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the GCM-Aetna-Facility-Carveouts fee schedule — when FacilityType in ASC, Hospital
  3. 100% of the GCM-Aetna-Clinic-Carveouts fee schedule
  4. 100% of the GCM-Aetna-TN01-AMFS-Clinic-Profees fee schedule — when FacilityGroup in Gastro One-AIG; FacilityType in Clinic
  5. 100% of the GCM-Aetna-TN03-AMFS-Clinic-Profees fee schedule — when FacilityGroup in GCM-Jackson, GCM-Skyline ASC-Jackson; FacilityType in Clinic
  6. 100% of the GCM-Aetna-TN01-AMFS-Facility-Profees fee schedule — when FacilityGroup in Gastro One-AIG; FacilityType in ASC, Hospital
  7. 100% of the GCM-Aetna-TN03-AMFS-Facility-Profees fee schedule — when FacilityGroup in GCM-Jackson, GCM-Skyline ASC-Jackson; FacilityType in ASC, Hospital
  8. 100% of the GCM-Aetna-TN02-AMFS-Facility-Profees fee schedule — when FacilityState in TN; FacilityType in ASC, Hospital
  9. 100% of the GCM-Aetna-TN02-AMFS-Clinic-Profees fee schedule — when FacilityState in TN; FacilityType in Clinic
  10. 100% of the GCM-Aetna-MS04-AMFS-Facility-Profees fee schedule — when FacilityState in MS; FacilityType in ASC, Hospital
  11. 100% of the GCM-Aetna-MS04-AMFS-Clinic-Profees fee schedule — when FacilityState in MS
  12. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GCM-Aetna Commercial Profees (Pre 2025)7 base · 18 adj
Aetna Commercial
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $539.96 — when ProcedureCode J2840 is present
  3. 140% of Medicare lab (TN, rates as of 2004-12-01)
  4. 100% of Medicare anesthesia
  5. 100% of Medicare drug
  6. 140% of Medicare DME (TN, rates as of 2004-12-01)
  7. 140% of Medicare RVU (rates as of 2004-12-01)
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-Aetna Medicare-Profee7 base · 18 adj
Aetna Medicare
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. flat $550.76 — when CodeRange in J2840–J2840
  3. 102% of Medicare lab
  4. 102% of Medicare drug
  5. 102% of Medicare DME
  6. 102% of Medicare RVU
  7. 102% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-Ambetter-Profees7 base · 18 adj
Ambetter, Centene
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 175% of Medicare lab
  3. 175% of Medicare drug
  4. 175% of Medicare DME
  5. 175% of Medicare RVU
  6. 175% of Medicare anesthesia
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-BCBS MS-Profee10 base · 14 adj
Anthem/BCBS Mississippi Commercial
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the GCM-BCBS-MS-Carveout-TopCodes fee schedule
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
  6. 100% of Medicare RVU
  7. 100% of Medicare anesthesia — when Modifier AA is present
  8. 100% of Medicare anesthesia — when Modifier QZ is present
  9. 100% of Medicare anesthesia — when Modifier QX is present
  10. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. cap each charge and the account total at 100% of billed charges
GCM-BCBS TN Medicare-Profee6 base · 18 adj
BCBS TN Medicare
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab (TN)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (TN)
  5. 100% of Medicare RVU
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-BCBS-TN-P Profee3 base · 18 adj
Anthem/BCBS Tennessee Network P
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-04-01 → 2025-09-30
Base terms — first match wins
  1. 100% of the GCM-BCBS TN-Network P-Hospital-Profees-Fee Schedule fee schedule — when FacilityType in Hospital, ASC
  2. 100% of the GCM-BCBS TN-Network P-Clinic-Profees-Fee Schedule fee schedule — when FacilityType in Clinic
  3. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 52 present → 50% of the running amount
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-BCBS-TN-P Profee3 base · 19 adj
Anthem/BCBS Tennessee Network P
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2025-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GCM-BCBS TN-Network P-Hospital-Profees-Fee Schedule fee schedule — when FacilityType in Hospital, ASC
  2. 100% of the GCM-BCBS TN-Network P-Clinic-Profees-Fee Schedule fee schedule — when FacilityType in Clinic
  3. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GCM-BCBS-TN-S Profee3 base · 18 adj
Anthem/BCBS Tennessee Network S
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-04-01 → 2025-09-30
Base terms — first match wins
  1. 100% of the GCM-BCBS TN-Network S-Hospital-Profees fee schedule — when FacilityType in ASC, Hospital
  2. 100% of the GCM-BCBS TN-Network S-Clinic-Profees fee schedule — when FacilityType in Clinic
  3. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 52 present → 50% of the running amount
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-BCBS-TN-S Profee3 base · 19 adj
Anthem/BCBS Tennessee Network S
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2025-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GCM-BCBS TN-Network S-Hospital-Profees fee schedule — when FacilityType in ASC, Hospital
  2. 100% of the GCM-BCBS TN-Network S-Clinic-Profees fee schedule — when FacilityType in Clinic
  3. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 52 present → 50% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GCM-Cigna Commercial-Profee7 base · 18 adj
Cigna Commercial
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-06-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the GCM-Cigna-Facility-Midlevel-Profees fee schedule — when FacilityType in ASC, Home, Hospital; ProviderType in Clinical Nurse Specialist, Mid-Level Provider, Nurse Practitioner, Physician Assistant
  2. 100% of the GCM-Cigna-Clinic-Midlevel-Profees fee schedule — when FacilityType in Clinic; ProviderType in Clinical Nurse Specialist, Mid-Level Provider, Nurse Practitioner, Physician Assistant
  3. 100% of the GCM-Cigna-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  4. 100% of the GCM-Cigna-Clinic-Profees fee schedule — when FacilityType in Clinic
  5. 100% of the GCM-Cigna Commercial-Profee-Drug-FS fee schedule
  6. 100% of Medicare anesthesia
  7. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when ProcedureCode G0121 is absent; ProcedureCode G0105 is absent
  4. modifier 22 present → 135% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 78 present → 70% of the running amount
  9. modifier 80 present → 16% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 14% of the running amount
  13. modifier QY present → 50% of the running amount
  14. modifier QK present → 50% of the running amount
  15. modifier QX present → 50% of the running amount
  16. modifier QZ present → 85% of the running amount
  17. cap each charge and the account total at 100% of billed charges
  18. modifier 53 present → 50% of the running amount
GCM-Cigna IFP-Profee-Profee4 base · 18 adj
Cigna IFP
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GCM-Cigna IFP-Profee-FacilityProfee-Fees fee schedule — when FacilityType in Hospital, ASC
  2. 100% of the GCM-Cigna IFP-Profee-NonFacilityProfee-Fees fee schedule
  3. 100% of the GCM-Cigna Commercial-Profee-Drug-FS fee schedule
  4. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-Cigna Medicare-Profee6 base · 19 adj
Cigna Medicare
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab (TN)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (TN)
  5. 100% of Medicare RVU
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GCM-Humana Medicare-Profee2 base · 20 adj
Humana Medicare
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson · 2021-01-01 → 2025-08-31
Base terms — first match wins
  1. 100% of the Midsouth-Humana Medicare-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the Midsouth-Humana Medicare-NonFacility-Profee-Fee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. modifier 53 present → 29% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GCM-Humana Medicare-Profee-20262 base · 20 adj
Humana Medicare
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson · 2025-09-01 → 2026-03-31
Base terms — first match wins
  1. 100% of the GCM-Humana-Medicare-Hospital-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GCM-Humana-Medicare-Clinic-Profees fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. modifier 53 present → 29% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GCM-Humana Medicare-Profee-2026-043 base · 20 adj
Humana Medicare
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson · 2026-04-01 → 2099-12-31
Base terms — first match wins
  1. 100% of the GCM-Humana-Medicare-Hospital-Profees fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GCM-Humana-Medicare-Clinic-Profees fee schedule — when FacilityType in Clinic
  3. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. modifier 53 present → 29% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GCM-Humana commercial Profees2 base · 18 adj
Humana Commercial
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson · 2024-01-01 → 9999-12-31
Base terms — first match wins
  1. 100% of the GCM-Humana-Facility-Profees fee schedule — when FacilityType in ASC, Home, Hospital
    • CodeRange 88305–88305 → 150%
    • CodeRange 88312–88313 → 100%
  2. 100% of the GCM-Humana-Clinic-Profees fee schedule — when FacilityType in Clinic
    • CodeRange 88305–88305 → 150%
    • CodeRange 88312–88313 → 100%
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier 52 present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-MedBen-Profee6 base · 18 adj
MedBen
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 125% of Medicare lab
  3. 125% of Medicare drug
  4. 125% of Medicare DME
  5. 125% of Medicare RVU
  6. 125% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-United Healthcare Medicare-Profee7 base · 18 adj
United Healthcare Medicare
Profee · Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2025-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of Medicare anesthesia
  7. 35% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-United Healthcare-Profee6 base · 20 adj
UMR, United Healthcare Commercial
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2025-07-01 → 2025-09-30
Base terms — first match wins
  1. 60% of Medicare lab (rates as of 2020-01-01)
  2. 100% of Medicare drug
  3. 40% of Medicare DME (rates as of 2020-01-01)
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 99202–99499 → 165%
    • CodeRange 10021–40489 → 110%
    • CodeRange 92002–92499 → 125%
    • CodeRange 90281–99607 → 140%
    • CodeRange 97010–97799 → 90%
    • CodeRange 40490–49999 → 335%
    • CodeRange 50000–69999 → 110%
  6. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. modifier 52 present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GCM-United Healthcare-Profee6 base · 21 adj
UMR, United Healthcare Commercial
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson · 2025-10-01 → 2999-12-31
Base terms — first match wins
  1. 60% of Medicare lab (rates as of 2020-01-01)
  2. 100% of Medicare drug
  3. 40% of Medicare DME (rates as of 2020-01-01)
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU (rates as of 2020-01-01)
    • CodeRange 99202–99499 → 165%
    • CodeRange 10021–40489 → 110%
    • CodeRange 92002–92499 → 125%
    • CodeRange 97010–97799 → 90%
    • CodeRange 50000–69999 → 110%
    • CodeRange 40490–49999 → 335%
    • CodeRange 80000–89999 → 60%
    • CodeRange G0105–G0105 → 335%
    • CodeRange G0121–G0121 → 335%
    • CodeRange 70000–79999 → 120%
  6. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. modifier 52 present → 50% of the running amount
  20. modifier 53 present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
GCM-Wellpoint-Profee2 base · 18 adj
Wellpoint
Profee · ECNM-GANM, Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the GCM-Wellpoint-Profees fee schedule
  2. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GHP - Anthem Commercial Profees7 base · 20 adj
Anthem Commercial Plans
Profee · GHP, ASC, Clinic, Home, Hospital · 2023-02-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare drug — when CodeRange in J0120–J9999
  3. 100% of the KY/IN-GHP-Anthem Commercial-Facility-POS24-Profee fee schedule — when PlaceOfService 24 is present
  4. 100% of the KY/IN-GHP-Anthem Commercial-Facility-Profee-2023 fee schedule — when FacilityType in ASC, Home, Hospital; CodeRange in 80000–89999
  5. 100% of the KY/IN-GHP-Anthem Commercial-Facility-Profee-2023 fee schedule — when FacilityType in ASC, Home, Hospital
  6. 100% of the KY/IN-GHP-Anthem Commercial-Non-Facility-Profee-2023 fee schedule — when FacilityType in Clinic; CodeRange in 80000–89999
  7. 100% of the KY/IN-GHP-Anthem Commercial-Non-Facility-Profee-2023 fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 3; pays 100/25/50/50/50/50%
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 53 present → 50% of the running amount
  19. modifier 52 present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GHP-Aetna Commercial Profees5 base · 18 adj
Aetna Commercial
Profee · GHP · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the GHP-Aetna-Indiana-Clinic-Profee fee schedule — when FacilityState in IN; FacilityType in Clinic
  3. 100% of the GHP-Aetna-Indiana-Hospital-Profee fee schedule — when FacilityState in IN; FacilityType in ASC, Hospital
  4. 100% of the GHP-Aetna-LouisvilleKY-Hospital-Profee fee schedule — when FacilityType in ASC, Hospital; FacilityState in KY
  5. 100% of the GHP-Aetna-LouisvilleKY-Clinic-Profee fee schedule — when FacilityType in Clinic; FacilityState in KY
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GHP-CareSource-Profee6 base · 18 adj
Caresource
Profee · GHP · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GHP-Humana-Medicare-Profee3 base · 18 adj
Humana Medicare
Profee · GHP · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the GHP-Humana-Medicare-Clinic-Profee fee schedule — when FacilityType in Clinic
  3. 100% of the GHP-Humana-Medicare-Facility-Profee fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GHP-Humana-Profee3 base · 18 adj
Humana Commercial
Profee · GHP · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the GHP-Humana-Clinic-Profee fee schedule — when FacilityType in Clinic
  3. 100% of the GHP-Humana-Facility-Profee fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GHP-Medicaid-Profee4 base · 20 adj
Medicaid
Profee · GHP, KY · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 45% of billed charges — when KYMedicaidBCCode True is present
  2. 100% of the Fixed-Fees-Lab fee schedule
  3. 100% of the KY-Medicaid-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the KY-Medicaid-Facility-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GHP-Molina-MedicaidKY-Profee4 base · 20 adj
Molina, Molina Medicaid, Molina Medicare
Profee · GHP · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 45% of billed charges — when KYMedicaidBCCode True is present
  2. 100% of the Fixed-Fees-Lab fee schedule
  3. 100% of the KY-Medicaid-Profee-Fees fee schedule — when FacilityType in Clinic
  4. 100% of the KY-Medicaid-Facility-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Same global-surgery post-op allocation as hash c5fd5754fcf4a52d (Allowed/GlobalDays*PostOpRate), but hardened: falls back to returning {Allowed} unchanged when GLOB_DAYS or POST_OP is missing/non-numeric/zero instead of dividing by zero. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GHP-Multiplan-Profee6 base · 20 adj
MultiPlan
Profee · GHP · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 131% of Medicare lab
  2. 126% of Medicare drug
  3. 121% of Medicare DME
  4. 100% of Medicare anesthesia
  5. 100% of Medicare RVU
    • ProcedureCategory Evaluation & Management → 129%
    • ProcedureCategory Surgery → 154%
    • ProcedureCategory Radiology → 150%
    • ProcedureCategory Pathology & Laboratory → 150%
    • ProcedureCategory Medicine Services → 149%
    • ProcedureCategory A-Codes, C-Codes, D-Codes +5 → 130%
  6. 70% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. modifier 52 present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GHP-United Healthcare-Profee6 base · 20 adj
United Healthcare Commercial, United Healthcare Options PPO
Profee · GHP · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the GHP-United Healthcare-NonFac-MidLevel-Profee fee schedule — when FacilityType in Clinic; ProviderType in Certified Registered Nurse anesthesiologist, Mid-Level Provider, Nurse Anesthetist, Certified Registered, Nurse Practitioner +2
  3. 100% of the GHP-United Healthcare-Fac-MidLevel-Profee fee schedule — when FacilityType in ASC, Home, Hospital; ProviderType in Certified Registered Nurse anesthesiologist, Mid-Level Provider, Nurse Anesthetist, Certified Registered, Nurse Practitioner +2
  4. 100% of the GHP-United Healthcare-NonFac-MD-Profee fee schedule — when FacilityType in Clinic
  5. 100% of the GHP-United Healthcare-Fac-MD-Profee fee schedule — when FacilityType in ASC, Home, Hospital
  6. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 3; pays 100/50%
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50% — when Modifier 55 is absent
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier 52 present → 50% of the running amount
  19. modifier 53 present → 25% of the running amount
  20. cap each charge and the account total at 100% of billed charges
GHP-WellCare-Profee6 base · 18 adj
WellCare Commercial
Profee · GHP · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 160% of Medicare lab
  3. 160% of Medicare drug
  4. 160% of Medicare DME
  5. 160% of Medicare RVU
  6. 160% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
IN - VA CCN Profee2 base · 19 adj
VA CCN
Profee · GHP, IN · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the IN-VACCN-Profee-Clinic fee schedule — when FacilityType in Clinic
  2. 100% of the IN-VACCN-Profee-Facility fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
KY/IN-GHP-Aetna Medicare-Profee5 base · 18 adj
Aetna Medicare
Profee · GHP, ASC, Clinic, Home, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
KY/IN-GHP-Anthem Medicare-Profee6 base · 18 adj
Anthem Medicare Plans
Profee · GHP, ASC, Clinic, Home, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier 52 present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
KY/IN-GHP-Cigna Commercial-Profee3 base · 16 adj
Cigna Commercial
Profee · GHP · 2024-07-15 → 9999-12-31
Base terms — first match wins
  1. 100% of the GHP-Cigna Comm-NonFacility-Profee-Fee fee schedule — when FacilityType in Clinic
  2. 100% of the GHP-Cigna-Comm-Facility-Profee-Fee fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. modifier 22 present → 135% of the running amount
  5. modifier 54 present → 80% of the running amount
  6. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  7. modifier 62 present → 62.5% of the running amount
  8. modifier 78 present → 70% of the running amount
  9. modifier 80 present → 16% of the running amount
  10. modifier 81 present → 16% of the running amount
  11. modifier 82 present → 16% of the running amount
  12. modifier AS present → 14% of the running amount
  13. modifier QY present → 50% of the running amount
  14. modifier QK present → 50% of the running amount
  15. modifier QX present → 50% of the running amount
  16. cap each charge and the account total at 100% of billed charges
LEG-Anthem-Medicare-Profee2 base · 18 adj
Anthem Medicare Plans
Profee · LEG-CSLC, ASC, Clinic, Home, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
MS - VA CCN Profee3 base · 19 adj
VA CCN
Profee · ECNM-GANM, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, MS · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the MS-VACCN-Profee-Clinic fee schedule — when FacilityType in Clinic
  2. 100% of the MS-VACCN-Profee-Hospital fee schedule — when FacilityType in Clinic
  3. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Medicare6 base · 18 adj
Medicare
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/50/50/50/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare-ASC2 base · 18 adj
Medicare
Facility · all facilities · 2024-01-01 → 2999-12-31
BCBS TN Medicare
Facility · GCM-Skyline ASC-Jackson · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
OH - VA CCN Profee3 base · 19 adj
VA CCN
Profee · Dayton Gastro, Dayton Gastro - DDC, Dayton Gastro - GHS, Dayton Gastro-GLG, OH, OHIO · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Dayton-VACCN-Profee-Clinic fee schedule — when FacilityType in Clinic
  2. 100% of the Dayton-VACCN-Profee-Facility fee schedule — when FacilityType in Clinic
  3. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Skyline ASC-Aetna Commercial-Facility - 20252 base · 17 adj
Aetna Commercial
Facility · GCM-Skyline ASC-Jackson · 2025-08-01 → 2026-07-31
Base terms — first match wins
  1. 100% of the Skyline ASC-Aetna Commercial-Facility - 2024 fee schedule
  2. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Skyline ASC-Aetna Medicare-Facility3 base · 20 adj
Aetna Medicare
Facility · GCM - Skyline ASC, ASC, Clinic, Home, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
  3. 30% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-surgery reduction — pays 100/50%
  5. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Skyline ASC-BCBSTN P-Facility3 base · 18 adj
Anthem/BCBS Tennessee Network P
Facility · GCM-Skyline ASC-Jackson, ASC, Clinic, Home, Hospital · 2023-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Skyline-BCBSTNP-Facility fee schedule
  3. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/0/0/0/0%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Skyline ASC-BCBSTN S-Facility3 base · 17 adj
Anthem/BCBS Tennessee Network S
Facility · GCM-Skyline ASC-Jackson, ASC, Clinic, Home, Hospital · 2023-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of the Skyline-BCBSTNS-Facility fee schedule
  3. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/0/0/0/0%
  3. mid-level provider reduction (by NUCC taxonomy)
  4. modifier 22 present → 135% of the running amount
  5. modifier 52 present → 50% of the running amount
  6. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Skyline ASC-Cigna-Facility2 base · 18 adj
Cigna Commercial
Facility · GCM-Skyline ASC-Jackson, ASC, Clinic, Home, Hospital · 2023-03-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 160% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Skyline ASC-Cigna-IFP-Facility2 base · 18 adj
Cigna IFP
Facility · GCM-Skyline ASC-Jackson, ASC, Clinic, Home, Hospital · 2023-03-01 → 2025-02-28
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 145% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Skyline ASC-Cigna-IFP-Facility-20252 base · 18 adj
Cigna IFP
Facility · GCM-Skyline ASC-Jackson, ASC, Clinic, Home, Hospital · 2025-03-01 → 2099-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 150% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Skyline ASC-UHC Medicare-Facility3 base · 20 adj
United Healthcare Medicare
Facility · GCM-Skyline ASC-Jackson, ASC, Clinic, Home, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
  3. 25% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-surgery reduction — pays 100/50%
  5. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Skyline-Ambetter-ASC-Facility2 base · 18 adj
Ambetter, Centene
Facility · GCM-Skyline ASC-Jackson · 2025-05-16 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 170% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
SkylineASC-UHC-Comm-Facility2 base · 17 adj
UMR, United Healthcare Commercial
Facility · GCM-Skyline ASC-Jackson, ASC, Hospital · 2025-05-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the SkylineASC-UHC-Comm-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/25/25/25%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
TN - VA CCN Profee3 base · 19 adj
VA CCN
Profee · Gastro One-AIG, Gastro One-GANM, GCM-Gastro One, GCM-Jackson, GCM-Skyline ASC-Jackson, TN · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the TN-VACCN-Profee-Clinic fee schedule — when FacilityType in Clinic
  2. 100% of the TN-VACCN-Profee-Clinic fee schedule — when FacilityType in Clinic
  3. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Tricare-Profee8 base · 20 adj
Tricare
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 85% of the Tricare-Drug fee schedule — when FacilityGroup in GHP
  3. 100% of the Tricare-Drug fee schedule
  4. 85% of the Tricare-CMAC-Technical fee schedule — when FacilityGroup in GHP
  5. 100% of the Tricare-CMAC-Technical fee schedule
  6. 85% of the Tricare-CMAC fee schedule — when FacilityGroup in GHP
  7. 100% of the Tricare-CMAC fee schedule
  8. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent; Modifier 82 is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 73 present → 50% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
VA-LEG-Aetna-Commercial-Facility2 base · 17 adj
Aetna Commercial
Facility · LEG-CSLC · 2024-11-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the VA-LEG-Aetna-Commercial-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem-Commercial-Facility2 base · 17 adj
Anthem Commercial Plans
Facility · LEG-CSLC · 2025-03-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the VA-LEG-Anthem-Commercial-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem-HMO-Facility2 base · 17 adj
Anthem HMO
Facility · LEG-CSLC · 2025-03-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the VA-LEG-Anthem-HMO-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem-Pathway-Facility2 base · 17 adj
Anthem Pathway HMO
Facility · LEG-CSLC · 2025-03-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the VA-LEG-Anthem-Pathway-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
VA-LEG-Cigna-Commercial-Facility2 base · 17 adj
Cigna Commercial
Facility · LEG-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the VA-LEG-Cigna-Commercial-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50/25/0/0/0%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
VA-LEG-UHC-AllPayers-Facility2 base · 17 adj
United Healthcare Commercial
Facility · LEG-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the VA-LEG-UHC-AllPayers-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
VA-LEG-UHC-NetOnePPO-Facility2 base · 17 adj
United Healthcare Options PPO
Facility · LEG-CSLC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the VA-LEG-UHC-NetOnePPO-Facility-Fees fee schedule
  2. 0% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges

Cannot fire (27)

These have no contract map, or one whose insurance / bill-type / facility selection is empty, so nothing can ever resolve to them.

Anthem Medicare-Profee · no contract map5 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem-Dayton Gastro · contract map selects nothing5 base · 17 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2026-07-29 → 2999-12-31
Base terms — first match wins
  1. flat $200 — when CodeRange in 00100–01999
  2. 110% of the Dayton-Anthem-Comm-Carveout-POS24-Profee fee schedule
  3. 110% of the GLG-Anthem-Commercial-Facility-Profee-Fee-2024 fee schedule — when FacilityType in ASC, Home, Hospital
  4. 110% of the GLG-Anthem-Commercial-NonFacility-Profee-Fee-2024 fee schedule — when FacilityType in Clinic
  5. 100% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-radiology reduction — base codes 4
  2. Medicare bilateral-surgery adjustment
  3. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 54 present → 80% of the running amount
  7. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Dayton Gastro - UHC Commercial Profees · no contract map14 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. flat $0 — when NoncoverageStatus Noncovered is present
  3. 100% of the Dayton-UHC-Facility-Carveouts fee schedule — when FacilityType in ASC, Hospital
  4. 100% of the Dayton-UHC-Clinic-Carveouts fee schedule
  5. 100% of Medicare DME (rates as of 2020-12-01) ⚠︎ named “40% of 2020 Medicare DME (Locality 1520200)” but configured at 100%
  6. computed expression (operands follow)
  7. 100% of the Dayton-UHC-Multipliers fee schedule
  8. Multiply 100% of Medicare lab (rates as of 2020-12-01)
  9. computed expression (operands follow)
  10. 100% of the Dayton-UHC-Multipliers fee schedule
  11. Multiply 100% of Medicare drug
  12. computed expression (operands follow)
  13. 100% of the Dayton-UHC-Multipliers fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2020-12-01)
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Dayton Gastro - UHC Commercial Profees · no contract map14 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. flat $0 — when NoncoverageStatus Noncovered is present
  3. 100% of the Dayton-UHC-Facility-Carveouts fee schedule — when FacilityType in ASC, Hospital
  4. 100% of the Dayton-UHC-Clinic-Carveouts fee schedule
  5. 100% of Medicare DME (rates as of 2020-12-01) ⚠︎ named “40% of 2020 Medicare DME (Locality 1520200)” but configured at 100%
  6. computed expression (operands follow)
  7. 100% of the Dayton-UHC-Multipliers fee schedule
  8. Multiply 100% of Medicare lab (rates as of 2020-12-01)
  9. computed expression (operands follow)
  10. 100% of the Dayton-UHC-Multipliers fee schedule
  11. Multiply 100% of Medicare drug
  12. computed expression (operands follow)
  13. 100% of the Dayton-UHC-Multipliers fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2020-12-01)
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
GAVA - Aetna Profee - 2025 · no contract map7 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the GAVA-Aetna-Facility-Carveouts fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the GAVA-Aetna-Clinic-Carveouts fee schedule
  3. 100% of Medicare anesthesia
  4. 128% of the GAVA-Aetna-NV-Facility-Profees fee schedule — when VARegion NV is present; FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 146.25%
    • ProcedureCategory Surgery → 146%
    • ProcedureCategory Pathology & Laboratory → 135%
    • CodeRange 96365–96365 → 142%
    • CodeRange 96413–96415 → 143.25%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 135%
  5. 128% of the GAVA-Aetna-NV-Clinic-Profees fee schedule — when VARegion NV is present
    • ProcedureCategory Evaluation & Management → 146.25%
    • ProcedureCategory Surgery → 146%
    • ProcedureCategory Pathology & Laboratory → 135%
    • CodeRange 96365–96365 → 142%
    • CodeRange 96413–96415 → 143.25%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 135%
  6. 128% of the GAVA-Aetna-TideW-Facility-Profees fee schedule — when VARegion TW is present; FacilityType in ASC, Home, Hospital
    • ProcedureCategory Evaluation & Management → 146.25%
    • ProcedureCategory Surgery → 146%
    • ProcedureCategory Pathology & Laboratory → 135%
    • CodeRange 96365–96365 → 142%
    • CodeRange 96413–96415 → 143.25%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 135%
  7. 128% of the GAVA-Aetna-TideW-Clinic-Profees fee schedule — when VARegion TW is present
    • ProcedureCategory Evaluation & Management → 146.25%
    • ProcedureCategory Surgery → 146%
    • ProcedureCategory Pathology & Laboratory → 135%
    • CodeRange 96365–96365 → 142%
    • CodeRange 96413–96415 → 143.25%
    • CodeRange 96401–96401 → 138%
    • CodeRange J1745–J1745 → 135%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. mid-level provider reduction (by NUCC taxonomy)
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GAVA-Anthem HMO-Profee-2025 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 98.85% of the VA-GAPC-Anthem HMO-Facility-Profee-2025 fee schedule — when FacilityType in ASC, Home, Hospital
  2. 98.85% of the VA-GAPC-Anthem HMO-NonFacility-Profee-2025 fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
GCM-Humana Medicare-Profee · no contract map2 base · 1 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the an unmapped schedule fee schedule — when FacilityType in ASC, Home, Hospital
  2. 100% of the an unmapped schedule fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
KY/IN-GHP-Aetna Commercial-Profee · no contract map0 base · 0 adj
no contract map — cannot be resolved
LEG-Aetna Commercial Profees 2025 · no contract map1 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. mid-level provider reduction (by NUCC taxonomy)
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
LEG-Aetna Commercial Profees 2026 · no contract map1 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. mid-level provider reduction (by NUCC taxonomy)
  5. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
LEG-Aetna Medicare Profees · no contract map1 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare anesthesia
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
LEG-Anthem Commercial-Profee (2025) · no contract map3 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the VA-LEG-Anthem Commercial-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Hospital
  2. 100% of the None fee schedule
  3. custom SQL — Anthem GA anesthesia carveout fee-schedule amount for anesthesia CPT codes (00100-01999), selecting between a Nevada-specific and a Tidewater-specific carveout schedule based on a 'VA' locale code embedded in the charge.
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
LEG-Anthem HMO-Profee · no contract map3 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the VA-LEG-Anthem HMO-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Hospital
  2. 100% of the VA-LEG-Anthem HMO-NonFacility-Profee-Fee fee schedule
  3. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}.
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
LEG-Anthem Pathway-Profee · no contract map3 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the VA-LEG-Anthem Pathway HMO-Facility-Profee-2025 fee schedule — when FacilityType in ASC, Hospital
  2. 100% of the VA-LEG-Anthem Pathway HMO-NonFacility-Profee-2025 fee schedule
  3. custom SQL — Anesthesia fee-schedule lookup restricted to anesthesia CPT codes (00100-01999) for Anthem VA/NV, selecting between two Anthem carveout schedules ('GAVA-Anthem-NV-Anes-Carveouts' vs '...Tidewater-Anes-Carveouts') based on a geo-locale code embedded in {Codes}.
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 120% of the running amount
  7. modifier 53 present → 50% of the running amount
  8. modifier 54 present → 70% of the running amount
  9. modifier 55 present → 20% of the running amount
  10. modifier 56 present → 10% of the running amount
  11. modifier 62 present → 63% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
LEG-United Healthcare Commercial Profees · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
LEG-United Healthcare Options Profees · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare-Anes SQL Expression · no contract map7 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of Medicare anesthesia
  7. custom SQL — Medicare anesthesia allowed amount: resolves the facility's ZIP to a Medicare locality/carrier, looks up that carrier/locality's anesthesia conversion factor, adds physical-status bonus units (P3=+1, P4=+2, P5=+3) to the billed time units, and returns units times the conversion factor.
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Skyline ASC-BCBS TN Medicare Adv-Facility · no contract map2 base · 20 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. multiple-surgery reduction (contract rules) — pays 100/50%
  5. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  6. mid-level provider reduction (by NUCC taxonomy)
  7. modifier 22 present → 135% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem Commercial-Profee - 2025 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 109.71% of the VA-LEG-Anthem Commercial-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Home, Hospital
  2. 109.71% of the VA-LEG-Anthem Commercial-NonFacility-Profee-Fee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem Commercial-Profee - 2026 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 114.65% of the VA-LEG-Anthem Commercial-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Home, Hospital
  2. 114.65% of the VA-LEG-Anthem Commercial-NonFacility-Profee-Fee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem Commercial-Profee - 2027 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 120.38% of the VA-LEG-Anthem Commercial-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Home, Hospital
  2. 120.38% of the VA-LEG-Anthem Commercial-NonFacility-Profee-Fee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem HMO-Profee - 2025 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 98.85% of the VA-LEG-Anthem HMO-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Home, Hospital
  2. 98.85% of the VA-LEG-Anthem HMO-NonFacility-Profee-Fee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem HMO-Profee - 2026 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 103.3% of the VA-LEG-Anthem HMO-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Home, Hospital
  2. 103.3% of the VA-LEG-Anthem HMO-NonFacility-Profee-Fee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem HMO-Profee - 2027 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 108.47% of the VA-LEG-Anthem HMO-Facility-Profee-Fee fee schedule — when FacilityType in ASC, Home, Hospital
  2. 108.47% of the VA-LEG-Anthem HMO-NonFacility-Profee-Fee fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem Pathway HMO-Profee-2025 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 81.78% of the an unmapped schedule fee schedule — when FacilityType in ASC, Home, Hospital
  2. 81.78% of the an unmapped schedule fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem Pathway HMO-Profee-2026 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 85.46% of the an unmapped schedule fee schedule — when FacilityType in ASC, Home, Hospital
  2. 85.46% of the an unmapped schedule fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
VA-LEG-Anthem Pathway HMO-Profee-2027 · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 89.73% of the an unmapped schedule fee schedule — when FacilityType in ASC, Home, Hospital
  2. 89.73% of the an unmapped schedule fee schedule — when FacilityType in Clinic
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare bilateral-surgery adjustment
  4. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50% — when Modifier 55 is absent
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges