Customer detail

SGP

130
live contracts
11
cannot fire
19
calc types
4
SQL bodies
4
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment1,964
PercentOfFees156
FlatFee152
MedicareMultipleProcedureAdjustment140
LesserOfAdjustment140
MedicareMultipleEndoscopyAdjustment140
MedicareMultipleRadiologyAdjustment140
MidLevelProviderAdjustment137
MedicareRVU118
MedicareDrug73
MedicareLab63
CalculationBuilder58
MedicareDME54
MedicareASC34
FlatPercentOfCharges33
SqlExpression10
CaseRate5
PercentOfCharges2
FlatPercentageAdjustment1

Contracts

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

100% Medicare ASC Rates (Payer Products)4 base · 19 adj
Cigna Commercial
Facility · NJ · 2023-01-01 → 2999-12-31
Clover Commercial
Facility · NJ · 2023-01-01 → 2999-12-31
Anthem/BCBS Medicare Plans, BCBS Highmark Medicare
Facility · PA · 2023-01-01 → 2999-12-31
Geisinger Health Medicare Plans
Facility · PA · 2023-01-01 → 2999-12-31
Humana
Facility · PA · 2023-01-01 → 2999-12-31
Humana
Facility · NJ · 2023-01-01 → 2999-12-31
GHI
Facility · NY · 2023-01-01 → 2025-03-31
HIP
Facility · NY · 2023-01-01 → 2025-03-31
GHI Medicare
Facility · NY · 2023-01-01 → 2999-12-31
HIP Medicare
Facility · NY · 2023-01-01 → 2999-12-31
Healthfirst Commercial, Healthfirst Medicare Plans
Facility · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC
  3. 100% of Medicare ASC — when FacilityState in NY
  4. 100% of Medicare ASC — when FacilityState in NJ
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
100% Medicare Rates (Payer Products)5 base · 19 adj
BCBS Individual Network
Profee · NY · 2023-01-01 → 2999-12-31
Healthfirst Medicare Plans
Profee · NY · 2023-01-01 → 2999-12-31
Molina Medicare Plans
Profee · NY · 2023-01-01 → 2999-12-31
BCBS Medicare Plans
Profee · CT · 2023-01-01 → 2999-12-31
United Healthcare VA
Profee · NJ · 2024-01-01 → 2999-12-31
BCBS Medicare Plans
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid 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-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
80% of 2019 Medicare Rates5 base · 19 adj
BCBS/Healthplus JLJ Superior Vision
Profee · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 80% of Medicare lab (NY, rates as of 2019-01-01)
  3. 80% of Medicare drug (rates as of 2019-01-01)
  4. 80% of Medicare DME (NY, rates as of 2019-01-01)
  5. 80% of Medicare RVU (rates as of 2019-01-01)
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
CT - Aetna Commercial Profees2 base · 19 adj
Aetna Commercial Plans
Profee · CT · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
CT - Aetna Facility Fees3 base · 19 adj
Aetna Commercial Plans
Facility · CT · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. flat $0 — when Aetna Noncovered Facility Charge Noncovered is present
  3. case rate from CaseRate (All-level codes)
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
CT - Anthem/BCBS Commercial Plan Profees4 base · 19 adj
Anthem/BCBS Commercial Plans
Profee · CT · 2023-10-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the CT-Anthem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital
  3. 100% of the CT-Anthem-Profee-Fees fee schedule
  4. 100% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
CT - Cigna Profees2 base · 19 adj
Cigna Commercial
Profee · CT · 2023-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
CT - Connecticare Commercial + Exchange Profees2 base · 19 adj
Connecticare Commercial HMO, Connecticare Commercial Plans, Connecticare Exchange HMO, Connecticare Exchange Plans
Profee · CT · 2023-04-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
CT - Health New England Profees2 base · 19 adj
Health New England
Profee · CT · 2023-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
CT - United Healthcare Profees2 base · 20 adj
United Healthcare Commercial
Profee · CT · 2023-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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. modifier QZ present → 85% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Charges1 base · 0 adj
Charges
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Fees fee schedule
LIASC - Healthfirst Medicaid & Essential Facility2 base · 19 adj
Healthfirst Medicaid And Essential Plans
Facility · 6 named facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-Medicaid-APG-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
Medicare5 base · 19 adj
Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
Jefferson Health Plans Medicare
Profee · Progressive Laser Surgical Institute, Progressive Surgical Institute, Progressive Vision Institute, Progressive Vision Institute of Allentown, Progressive Vision Institute of Philadelphia · 2024-01-01 → 2999-12-31
Connecticare Medicare HMO, Connecticare Medicare Plans
Profee · CT · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid 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-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
Medicare-ASC2 base · 19 adj
Medicare
Facility · all facilities · 2023-01-01 → 2999-12-31
Molina Medicare Plans
Facility · NY · 2023-01-01 → 2999-12-31
Connecticare Medicare HMO, Connecticare Medicare Plans
Facility · CT · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Aetna Commercial Facility Fees4 base · 19 adj
Aetna Commercial Plans
Facility · NJ · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. flat $0 — when Aetna Noncovered Facility Charge Noncovered is present
  4. 100% of the NJ-Aetna-Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/0%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Aetna Commercial Profees2 base · 19 adj
Aetna Commercial Plans
Profee · NJ · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 108% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Aetna Medicare Facility Fees4 base · 19 adj
Aetna Medicare Plans
Facility · NJ · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. flat $0 — when Aetna Noncovered Facility Charge Noncovered is present
  4. 100% of the NJ-Aetna-Medicare-Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/0%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Aetna Medicare Profees3 base · 19 adj
Aetna Medicare Plans
Profee · NJ · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 106% of the NJ-Aetna-Medicare-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  3. 106% of the NJ-Aetna-Medicare-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Cigna Medicare6 base · 19 adj
Cigna Medicare
Profee · NJ · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 60% of Medicare lab
  3. 50% of Medicare DME
  4. 100% of Medicare drug
  5. 70% of Medicare RVU — when CPTCategory Radiology is present
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Clover Commercial Profees5 base · 19 adj
Clover Commercial
Profee · NJ · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 95% of Medicare lab
  3. 95% of Medicare drug
  4. 95% of Medicare DME
  5. 95% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Horizon Commercial Profees5 base · 19 adj
Anthem/BCBS Horizon
Profee · NJ · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 85% of Medicare lab
  3. 85% of Medicare drug
  4. 85% of Medicare DME
  5. 85% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Horizon Facility Fees1 base · 19 adj
Anthem/BCBS Horizon
Facility · NJ · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $1330.37
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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 40% of billed charges
NJ - Horizon Medicare Facility Fees1 base · 19 adj
Anthem/BCBS Medicare Plans, BCBS Horizon Managed Care
Facility · NJ · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $1119.46
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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 40% of billed charges
NJ - Horizon Product Profees2 base · 19 adj
Anthem/BCBS Horizon, Anthem/BCBS Medicare Plans, BCBS Horizon Managed Care
Profee · NJ · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Fees-OD fee schedule — when ProviderType Optometrist is present
  2. 100% of the Profee-Fees-MD fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - Humana Profees5 base · 19 adj
Humana
Profee · NJ · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 50% of Medicare lab
  3. 100% of Medicare drug
  4. 75% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - UHC Commercial Facility Fees3 base · 19 adj
United Healthcare Commercial
Facility · NJ · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of billed charges — when ProcedureCode V2785 is present
  3. 100% of the Grouper-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NJ - UHC Commercial Profees15 base · 20 adj
United Healthcare Commercial
Profee · NJ · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. computed expression (operands follow)
  4. 100% of the UHC-Medicare-Multiplier fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow)
  7. 100% of the UHC-Medicare-Multiplier fee schedule
  8. Multiply 100% of Medicare DME (NJ)
  9. computed expression (operands follow)
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (NJ)
  12. computed expression (operands follow)
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU
  15. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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. modifier QZ present → 85% of the running amount
  20. cap each charge and the account total at 100% of billed charges
NJ - UHC Medicare Facility Fees5 base · 19 adj
United Healthcare Medicare
Facility · NJ · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. case rate from CaseRate (All-level codes)
  3. percent-of-charges, rate read from the Percent-Of-Charges schedule
  4. 90% of Medicare ASC
  5. 90% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Aetna Commercial Facility Fees3 base · 19 adj
Aetna Commercial Plans
Facility · NY · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. flat $0 — when Aetna Noncovered Facility Charge Noncovered is present
  3. 100% of the NY-Aetna-Facility-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Aetna Commercial Profees10 base · 19 adj
Aetna Commercial Plans
Profee · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. flat $1089 — when ProcedureCode 66984 is present
  3. 100% of Medicare lab (rates as of 2018-12-01) — when Aetna2018MedicareCodes 2018medicare is present ⚠︎ named “57% of 2018 Medicare Laboratory/Pathology” but configured at 100%
  4. 100% of Medicare RVU (rates as of 2018-12-01) — when Aetna2018MedicareCodes 2018medicare is present
    • CodeRange 99201–99499 → 104%
    • CodeRange 92002–92136 → 106%
    • CodeRange 70010–77084 → 78%
    • CodeRange 78012–79999 → 78%
  5. 100% of Medicare DME
  6. 100% of Medicare drug
  7. 114% of Medicare RVU
  8. 100% of the NY-Aetna-Profee-Fees fee schedule — when FacilityType in Clinic
  9. 100% of the NY-Aetna-Facility-Profee-Fees fee schedule — when FacilityType in ASC
  10. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Aetna Government Programs Profees6 base · 19 adj
Aetna Medicare Plans
Profee · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare DME
  3. 100% of Medicare drug
  4. 100% of Medicare lab
  5. 100% of Medicare RVU
  6. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Affinity Medicaid8 base · 19 adj
Affinity Medicaid Plans
Profee · NY · 2023-01-01 → 2024-06-23
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 75% of Medicare RVU — when CPTCategory Evaluation & Management is present
  3. 80% of Medicare RVU — when CPTCategory Surgery is present
  4. 100% of the NY-Medicaid-Medical-Services-Profee-Fees fee schedule — when CPTCategory Pathology & Laboratory is present
  5. 70% of Medicare RVU — when CPTCategory Radiology is present
  6. 100% of Medicare drug
  7. flat $50 — when ProcedureCode 97597 is present
  8. 75% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Affinity Medicaid (2024)8 base · 19 adj
Affinity Medicaid Plans
Profee · NY · 2024-06-24 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. flat $50 — when ProcedureCode 97597 is present
  3. 100% of the NY-Medicaid-Surgery-Fixed-Fees fee schedule
  4. 100% of the NY-Medicaid-Medical-Services-Profee-Fees fee schedule
  5. 100% of Medicare RVU
  6. 100% of Medicare drug
  7. 100% of Medicare DME
  8. 100% of Medicare lab
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Affinity Medicaid Facility2 base · 19 adj
Affinity Medicaid Plans
Facility · NY · 2024-06-24 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-Medicaid-APG-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Affinity Medicare Facility2 base · 19 adj
Affinity Medicare Plans
Facility · NY · 2024-06-24 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Affinity Medicare Profees5 base · 19 adj
Affinity Medicare Plans
Profee · NY · 2023-01-01 → 2024-06-23
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 80% of Medicare lab
  3. 80% of Medicare drug
  4. 80% of Medicare DME
  5. 80% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Affinity Medicare Profees (2024)5 base · 19 adj
Affinity Medicare Plans
Profee · NY · 2024-06-24 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid 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-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Blue Access LIASC 7.1.20233 base · 19 adj
BCBS Empire Blue Access
Facility · LONG ISLAND AMBULATORY SURGERY CENTER, Long Island Ambulatory Surgery Center, LLC, Long Island Eye, Long Island Eye ASU, Long Island Eye Surgery Center, NY · 2023-07-01 → 2024-11-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 80% of Medicare ASC
  3. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Blue Connection LIASC 7.1.20233 base · 19 adj
BCBS Empire Blue Connection
Facility · LONG ISLAND AMBULATORY SURGERY CENTER, Long Island Ambulatory Surgery Center, LLC, Long Island Eye, Long Island Eye ASU, Long Island Eye Surgery Center, NY · 2023-07-01 → 2024-11-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 75% of Medicare ASC
  3. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Commercial Facility Fees4 base · 19 adj
Anthem/BCBS Commercial Plans, BCBS Empire Blue Access, BCBS Empire Blue Connection, BCBS Empire Commercial Plans
Facility · NY · 2024-11-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC
    • Insurance Anthem/BCBS Commercial Plans, BCBS Empire Commercial Plans → 113.5%
    • Insurance BCBS Empire Blue Access → 90.8%
    • Insurance BCBS Empire Blue Connection → 85.13%
  3. case rate from CaseRate (All-level codes)
  4. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Commercial Facility Fees pre 11.14.243 base · 19 adj
Anthem/BCBS Commercial Plans, BCBS Empire Blue Access, BCBS Empire Blue Connection, BCBS Empire Commercial Plans
Facility · Acct 220121, ASC of Westchester, Brooklyn, Cohens Childrens Hospital, Costco, Dobbs Ferry Pavilion, Eastern Long Island Hospital, Empire Surgical Center, Eye Surgery Center of Westchester, Garden City 1055, Garden City 1055 Lasik, Garden City Surgi Center, Garden City Surgicenter, Good Sam ASC, Good Samaritan Hospital, Good Samaritan Hospital Medical Center, Good Samaritan Medical Center, Gramercy Surgery Center, Greater Binghamton Eye Surgery Center, Hewlett, Hudson Yards, Huntington Hospital, Island Eye Surgery Center, John T Mather Hospical, Johnson City Optical, Kelly Lasik, Lasik Center, Lasik of New York PLLC, Lindenhurst Eye Physicians and Surgeons Amityville, Lindenhurst Eye Physicians and Surgeons West Islip, Manhattan Eye and Ear, Manhattan Surgery Center, Melville Sugery Center, Mid Island Eye Physicians & Surgeons, Midtown Surgery Center, Montefiore Hutchinson Ambulatory Surgery Center, Mount Sinai South Nassau Hospital, Nassau University Medical Center, Nesconset Nursing Home, New York Community Hospital, North Queens Surgery Center, North Shore Eye Care, North Shore Surgi Center, NY Community Hospital, NY Eye and Ear Infirmary, NYU Langone, Park Avenue LASEK, Peconic Bay Medical Center, Port Jefferson ASC, LLC, Queen of Peace, Queens Surgical Center, Retinal Ambulatory Surgery Center, Rockville Centre 100 Merrick, Rockville Centre 200 Maple, RVC 100 Lasik, RVC 220 Lasik, Sheepshead Bay Surgery Center, Sight MD Medical Doctors, Sight Medical Doctors, Sight Medical Doctors PLLC, Sight Medical Doctors, PLLC, SightMD Medical Doctors PLLC, Skinney Med Spa, South Hampton Hospital, South Shore Ambulatory Surgery Center, Southside Hospital, SouthSide Hospital LIJ, St Johns Episcopal Hospital, St Johns ER, St Johns Riverside Hospit, St Johns Riverside Hospital, St. Catherine of Sienna Medical Center, St. Catherine of Sienna Nursing, ST. JOSEPH HOSPITAL, STAHL EYE CENTER, Suffolk Surgery Center, Surgical Specialty Center of Westchester, Syosset Hospital, Syosset Surgi Center, The Ambulatory Surgery Center of Greater New York, The Mackool Eye Institute, TLC, TLC Laser Eye Center, UHS Binghamton General Hospital, UHS Wilson Medical Center, Westchester Square Medical Center, White Plains Hospital, Winthrop Ambulatory Surgery Center, Winthrop Hospital, Wyckoff Heights Medical Center, Yorktown Center for Specialty Surgery, NY · 2023-01-01 → 2024-11-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-BCBS-Grouper-Rates fee schedule
  3. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire Blue Access Profees (2023)6 base · 19 adj
BCBS Empire Blue Access
Profee · NY · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 115% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 115% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire Blue Access Profees (2024)6 base · 19 adj
BCBS Empire Blue Access
Profee · NY · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 118% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 118% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire Blue Access Profees (2025)6 base · 19 adj
BCBS Empire Blue Access
Profee · NY · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 122% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 122% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire Blue Connection Profees (2023)6 base · 19 adj
BCBS Empire Blue Connection
Profee · NY · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 106% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 106% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire Blue Connection Profees (2024)6 base · 19 adj
BCBS Empire Blue Connection
Profee · NY · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 109% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 109% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire Blue Connection Profees (2025)6 base · 19 adj
BCBS Empire Blue Connection
Profee · NY · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 113% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 113% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire HMO/PPO/Imdemnity Profees (2023)6 base · 19 adj
BCBS Empire Commercial Plans
Profee · NY · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 140% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 140% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire HMO/PPO/Imdemnity Profees (2024)6 base · 19 adj
BCBS Empire Commercial Plans
Profee · NY · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 144% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 144% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Empire HMO/PPO/Imdemnity Profees (2025)6 base · 19 adj
BCBS Empire Commercial Plans
Profee · NY · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 148% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 148% of Medicare RVU (rates as of 2015-01-01)
  6. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS LIASC 7.1.20233 base · 19 adj
Anthem/BCBS Commercial Plans, BCBS Empire Commercial Plans
Facility · LONG ISLAND AMBULATORY SURGERY CENTER, Long Island Ambulatory Surgery Center, LLC, Long Island Eye, Long Island Eye ASU, Long Island Eye Surgery Center, NY · 2023-07-01 → 2024-11-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC
  3. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS Medicare Profees5 base · 19 adj
BCBS Medicare Plans
Profee · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare lab (NY)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NY)
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS/Excellus Commercial (2024)3 base · 19 adj
BCBS/Excellus Commercial
Profee · NY · 2024-10-01 → 2025-11-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-BCBS/Excellus-MD-Clinic fee schedule — when FacilityType in Clinic
  3. 100% of the NY-BCBS/Excellus-MD-Facility fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS/Excellus Commercial (2025)4 base · 19 adj
BCBS/Excellus Commercial
Profee · NY · 2025-11-15 → 2025-12-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees-Injections fee schedule
  3. 100% of the NY-BCBS/Excellus-MD-Clinic fee schedule — when FacilityType in Clinic
  4. 100% of the NY-BCBS/Excellus-MD-Facility fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS/Excellus Commercial (2026)6 base · 19 adj
BCBS/Excellus Commercial
Profee · NY · 2025-12-15 → 2099-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees-Injections fee schedule
  3. 100% of the NY-BCBS/Excellus-OD-Clinic fee schedule — when ProviderType Optometrist is present; FacilityType in Clinic
  4. 100% of the NY-BCBS/Excellus-OD-Facility fee schedule — when ProviderType Optometrist is present; FacilityType in ASC, Hospital
  5. 100% of the NY-BCBS/Excellus-MD-Clinic fee schedule — when FacilityType in Clinic
  6. 100% of the NY-BCBS/Excellus-MD-Facility fee schedule — when FacilityType in ASC, Hospital
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS/Excellus Medicare5 base · 19 adj
BCBS/Excellus Medicare
Profee · NY · 2025-04-01 → 2026-03-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid 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-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - BCBS/Excellus Medicare5 base · 19 adj
BCBS/Excellus Medicare
Profee · NY · 2026-04-01 → 2099-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid 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-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Brighton Health Profees7 base · 19 adj
Brighton Health
Profee · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. flat $1000 — when ProcedureCode 66982 is present
  3. flat $800 — when ProcedureCode 66984 is present
  4. 100% of Medicare lab
  5. 100% of Medicare drug
  6. 100% of Medicare DME
  7. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Cigna Facility Fees3 base · 19 adj
Cigna Commercial
Facility · NY · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 120% of Medicare ASC
  3. 120% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Cigna Facility Fees (pre 5.1.2024)2 base · 19 adj
Cigna Commercial
Facility · NY · 2023-01-01 → 2024-04-30
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Grouper-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Cigna Profees27 base · 19 adj
Cigna Commercial
Profee · NY · 2024-03-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  4. custom SQL — Looks up a Medicare-conversion multiplier ('MD/OD' rate) for NY Cigna claims, selected by whether the procedure's CPT category is Surgery vs everything else, as of the most recent effective date on/before the service date.
  5. Multiply 100% of Medicare lab (rates as of 2023-01-01)
  6. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  7. custom SQL — Looks up a Medicare-conversion multiplier ('MD/OD' rate) for NY Cigna claims, selected by whether the procedure's CPT category is Surgery vs everything else, as of the most recent effective date on/before the service date.
  8. Multiply 100% of Medicare drug (rates as of 2023-01-01)
  9. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  10. custom SQL — Looks up a Medicare-conversion multiplier ('MD/OD' rate) for NY Cigna claims, selected by whether the procedure's CPT category is Surgery vs everything else, as of the most recent effective date on/before the service date.
  11. Multiply 100% of Medicare DME (rates as of 2023-01-01)
  12. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  13. custom SQL — Looks up a Medicare-conversion multiplier ('MD/OD' rate) for NY Cigna claims, selected by whether the procedure's CPT category is Surgery vs everything else, as of the most recent effective date on/before the service date.
  14. Multiply 100% of Medicare RVU (rates as of 2023-01-01)
  15. computed expression (operands follow) — when UHCPhysicianStatus Non-Physician is present
  16. custom SQL — Companion to idx30: looks up the 'Non-MD/OD' Medicare conversion multiplier for NY Cigna claims, selected by CPT surgery-category and most-recent effective date -- the two snippets are almost certainly paired via a provider-type branch elsewhere in the same FeeLogic.
  17. Multiply 100% of Medicare lab (rates as of 2023-01-01)
  18. computed expression (operands follow) — when UHCPhysicianStatus Non-Physician is present
  19. custom SQL — Companion to idx30: looks up the 'Non-MD/OD' Medicare conversion multiplier for NY Cigna claims, selected by CPT surgery-category and most-recent effective date -- the two snippets are almost certainly paired via a provider-type branch elsewhere in the same FeeLogic.
  20. Multiply 100% of Medicare drug (rates as of 2023-01-01)
  21. computed expression (operands follow) — when UHCPhysicianStatus Non-Physician is present
  22. custom SQL — Companion to idx30: looks up the 'Non-MD/OD' Medicare conversion multiplier for NY Cigna claims, selected by CPT surgery-category and most-recent effective date -- the two snippets are almost certainly paired via a provider-type branch elsewhere in the same FeeLogic.
  23. Multiply 100% of Medicare DME (rates as of 2023-01-01)
  24. computed expression (operands follow) — when UHCPhysicianStatus Non-Physician is present
  25. custom SQL — Companion to idx30: looks up the 'Non-MD/OD' Medicare conversion multiplier for NY Cigna claims, selected by CPT surgery-category and most-recent effective date -- the two snippets are almost certainly paired via a provider-type branch elsewhere in the same FeeLogic.
  26. Multiply 100% of Medicare RVU (rates as of 2023-01-01)
  27. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Cigna Profees (Pre 3.1.2024)8 base · 19 adj
Cigna Commercial
Profee · NY · 2023-01-01 → 2024-02-28
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare lab (rates as of 2017-01-01)
  3. 100% of Medicare drug (rates as of 2017-01-01)
  4. 100% of Medicare drug (rates as of 2023-01-01)
  5. 100% of Medicare drug (rates as of 2024-01-01)
  6. 100% of Medicare DME (rates as of 2017-01-01)
  7. 100% of Medicare RVU (rates as of 2017-01-01)
  8. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Elderplan Profees (2023/2024)6 base · 19 adj
Elderplan
Profee · NY · 2023-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. computed expression (operands follow)
  4. 100% of the NY-Elderplan-Profee-Fees fee schedule
  5. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  6. Multiply 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Elderplan Profees 20253 base · 19 adj
Elderplan
Profee · NY · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. 100% of the NY-Elderplan-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Emblem Facility Fees2 base · 19 adj
GHI
Facility · NY · 2025-04-01 → 2999-12-31
HIP
Facility · NY · 2025-04-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 130% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Emblem Profees (GHI/HIP)3 base · 19 adj
GHI
Profee · NY · 2023-01-01 → 2025-07-14
GHI/CBP
Profee · NY · 2024-01-01 → 2025-07-14
HIP
Profee · NY · 2023-01-01 → 2025-07-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  3. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Empire Facility Fees pre 20243 base · 19 adj
Empire NYShip
Facility · ASC, Clinic, Clinical, Surgical · 2023-01-01 → 2024-10-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 120% of Medicare ASC (rates as of 2013-12-01) ⚠︎ named “100% 2013 Medicare ASC (Nassau County-Suffolk County, NY)” but configured at 120%
    • CodeRange 65091–68899 → 100%
    • CodeRange 20000–29999 → 100%
  3. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/0%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Fidelis Facility Fees3 base · 19 adj
Fidelis
Facility · NY · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 95% of Medicare ASC
  3. 95% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Fidelis Profees (2023)6 base · 19 adj
Fidelis Essentials, Fidelis Medicaid, Fidelis Medicare
Profee · NY · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. computed expression (operands follow)
  4. 100% of the NY-Fidelis-Profee-Fees fee schedule
  5. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  6. Multiply 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Fidelis Profees (2024)23 base · 19 adj
Fidelis Essentials, Fidelis Medicaid, Fidelis Medicare
Profee · NY · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. 83% of Medicare RVU — when NYNMNewProvider New is present
  4. computed expression (operands follow) — when Provider 32887-SightMD-NY is present
  5. 100% of the NY-Fidelis-Profee-Fees fee schedule
  6. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  7. Multiply 100% of Medicare RVU
  8. computed expression (operands follow) — when Provider 32903-SightMD-NY is present
  9. 100% of the NY-Fidelis-Profee-Fees fee schedule
  10. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  11. Multiply 100% of Medicare RVU
  12. computed expression (operands follow) — when Provider 32950-SightMD-NY is present
  13. 100% of the NY-Fidelis-Profee-Fees fee schedule
  14. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  15. Multiply 100% of Medicare RVU
  16. computed expression (operands follow) — when Provider 33065-SightMD-NY is present
  17. 100% of the NY-Fidelis-Profee-Fees fee schedule
  18. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  19. Multiply 100% of Medicare RVU
  20. computed expression (operands follow) — when Provider 33068-SightMD-NY is present
  21. 100% of the NY-Fidelis-Profee-Fees fee schedule
  22. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  23. Multiply 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Fidelis Profees 20253 base · 19 adj
Fidelis Essentials, Fidelis Medicaid, Fidelis Medicare
Profee · NY · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. 83% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - GHI Profees 7.15.258 base · 19 adj
GHI, GHI/CBP
Profee · NY · 2025-07-15 → 2026-07-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 85% of Medicare RVU — when ProcedureCategory in Radiology
  3. 160% of Medicare RVU — when CodeRange in 66982–66982; CodeRange in 66984–66984; CodeRange in 66991–66991; CodeRange in 67028–67028
  4. 60% of Medicare lab
  5. 85% of Medicare RVU
  6. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  7. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  8. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - GHI Profees 7.15.268 base · 19 adj
GHI, GHI/CBP
Profee · NY · 2026-07-15 → 2027-07-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare RVU — when ProcedureCategory in Radiology
  3. 160% of Medicare RVU — when CodeRange in 66982–66982; CodeRange in 66984–66984; CodeRange in 66991–66991; CodeRange in 67028–67028
  4. 60% of Medicare lab
  5. 90% of Medicare RVU
  6. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  7. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  8. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - GHI Profees 7.15.278 base · 19 adj
GHI, GHI/CBP
Profee · NY · 2027-07-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare RVU — when ProcedureCategory in Radiology
  3. 160% of Medicare RVU — when CodeRange in 66982–66982; CodeRange in 66984–66984; CodeRange in 66991–66991; CodeRange in 67028–67028
  4. 60% of Medicare lab
  5. 95% of Medicare RVU
  6. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  7. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  8. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - HIP Enhanced Care Prime Network Profees3 base · 19 adj
HIP Enhanced Care Prime
Profee · NY · 2018-10-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-HIP-Enhanced-Care-Prime fee schedule
  3. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - HIP Medicare Profees 7.15.257 base · 19 adj
HIP Medicare
Profee · NY · 2025-07-15 → 2026-07-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare RVU — when ProcedureCategory in Radiology
  3. 60% of Medicare lab
  4. 90% of Medicare RVU
  5. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  6. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - HIP Medicare Profees 7.15.267 base · 19 adj
HIP Medicare
Profee · NY · 2026-07-15 → 2027-07-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare RVU — when ProcedureCategory in Radiology
  3. 60% of Medicare lab
  4. 95% of Medicare RVU
  5. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  6. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - HIP Medicare Profees 7.15.277 base · 19 adj
HIP Medicare
Profee · NY · 2027-07-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare RVU — when ProcedureCategory in Radiology
  3. 60% of Medicare lab
  4. 100% of Medicare RVU
  5. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  6. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - HIP Profees 7.15.257 base · 19 adj
HIP, HIP/CBP
Profee · NY · 2025-07-15 → 2026-07-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 85% of Medicare RVU — when ProcedureCategory in Radiology
  3. 60% of Medicare lab
  4. 90% of Medicare RVU
  5. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  6. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - HIP Profees 7.15.267 base · 19 adj
HIP, HIP/CBP
Profee · NY · 2026-07-15 → 2027-07-14
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare RVU — when ProcedureCategory in Radiology
  3. 60% of Medicare lab
  4. 95% of Medicare RVU
  5. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  6. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - HIP Profees 7.15.277 base · 19 adj
HIP, HIP/CBP
Profee · NY · 2027-07-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare RVU — when ProcedureCategory in Radiology
  3. 60% of Medicare lab
  4. 100% of Medicare RVU
  5. 100% of the NY-Emblem-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  6. 100% of the NY-Emblem-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Healthfirst Commercial (1.1.19 to 7.31.23)5 base · 19 adj
Healthfirst Commercial
Profee · NY · 2023-01-01 → 2023-07-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 88% of Medicare lab
  3. 88% of Medicare drug
  4. 88% of Medicare DME
  5. 88% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Healthfirst Commercial (8.1.23 to 7.31.24)5 base · 19 adj
Healthfirst Commercial
Profee · NY · 2023-08-01 → 2024-07-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare lab
  3. 90% of Medicare drug
  4. 90% of Medicare DME
  5. 90% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Healthfirst Commercial (8.1.24 to 7.31.25)5 base · 19 adj
Healthfirst Commercial
Profee · NY · 2024-08-01 → 2025-07-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 92% of Medicare lab
  3. 92% of Medicare drug
  4. 92% of Medicare DME
  5. 92% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Healthfirst Commercial (8.1.25 to 7.31.26)5 base · 19 adj
Healthfirst Commercial
Profee · NY · 2025-08-01 → 2026-07-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 94% of Medicare lab
  3. 94% of Medicare drug
  4. 94% of Medicare DME
  5. 94% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - MagnaCare Profees (8.1.2024)7 base · 19 adj
MagnaCare
Profee · NY · 2024-08-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. flat $1000 — when ProcedureCode 66982 is present
  3. flat $800 — when ProcedureCode 66984 is present
  4. 100% of Medicare lab
  5. 100% of Medicare drug
  6. 100% of Medicare DME
  7. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Magnacare Profees2 base · 19 adj
MagnaCare
Profee · NY · 2024-01-01 → 2024-07-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Molina Medicaid, FHP & CHP7 base · 19 adj
Molina Medicaid Plans
Profee · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare RVU — when CPTCategory Evaluation & Management is present
  3. 90% of Medicare RVU — when CPTCategory Surgery is present
  4. 90% of Medicare RVU — when CPTCategory Medicine Services is present
  5. 100% of Medicare drug
  6. 100% of the NY-Medicaid-Radiology-Fixed-Fees fee schedule
  7. 100% of the NY-Medicaid-Medical-Services-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - NYNM Profees (2023/2024)6 base · 20 adj
NYNM
Profee · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. computed expression (operands follow)
  4. 100% of the NY-NYNM-Profee-Fees fee schedule
  5. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  6. Multiply 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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. rescale to 88% of the running amount ⚠︎ named “12% Management Fee” but configured at 88%
  20. cap each charge and the account total at 100% of billed charges
NY - UHC Commercial Profees (9.1.2024)27 base · 19 adj
UHC Oxford/Freedom, UHC Oxford/Liberty, UHC Oxford/Metro, UHC/Compass/Navigate/Core, United Healthcare Commercial
Profee · NY · 2024-09-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  4. 100% of the UHC-Medicare-Multiplier fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  7. 100% of the UHC-Medicare-Multiplier fee schedule
  8. Multiply 100% of Medicare DME (NY, rates as of 2020-01-01)
  9. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (NY, rates as of 2020-01-01)
  12. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  15. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  16. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  17. Multiply 100% of Medicare drug
  18. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  19. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  20. Multiply 100% of Medicare DME (NY, rates as of 2020-01-01)
  21. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  22. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  23. Multiply 100% of Medicare lab (NY, rates as of 2020-01-01)
  24. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  25. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  26. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  27. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 55 present → 20% 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. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
NY - UHC Empire Profees27 base · 19 adj
Empire NYShip
Profee · NY · 2023-02-01 → 2025-06-30
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  4. 100% of the UHC-Medicare-Multiplier fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  7. 100% of the UHC-Medicare-Multiplier fee schedule
  8. Multiply 100% of Medicare DME (NY, rates as of 2019-01-01)
  9. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (NY, rates as of 2019-01-01)
  12. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2019-01-01)
  15. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  16. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  17. Multiply 100% of Medicare drug
  18. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  19. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  20. Multiply 100% of Medicare DME (NY, rates as of 2019-01-01)
  21. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  22. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  23. Multiply 100% of Medicare lab (NY, rates as of 2019-01-01)
  24. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  25. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  26. Multiply 100% of Medicare RVU (rates as of 2019-01-01)
  27. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - UHC Empire Profees-202527 base · 19 adj
Empire NYShip
Profee · NY · 2025-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  4. 100% of the UHC-Medicare-Multiplier fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  7. 100% of the UHC-Medicare-Multiplier fee schedule
  8. Multiply 100% of Medicare DME (NY, rates as of 2023-01-01)
  9. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (NY, rates as of 2023-01-01)
  12. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2023-01-01)
  15. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  16. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  17. Multiply 100% of Medicare drug
  18. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  19. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  20. Multiply 100% of Medicare DME (NY, rates as of 2023-01-01)
  21. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  22. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  23. Multiply 100% of Medicare lab (NY, rates as of 2023-01-01)
  24. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  25. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  26. Multiply 100% of Medicare RVU (rates as of 2023-01-01)
  27. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - UHC Medicare Facility Fees5 base · 19 adj
United Healthcare Medicare
Facility · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. case rate from CaseRate (All-level codes)
  3. percent-of-charges, rate read from the Percent-Of-Charges schedule
  4. 100% of Medicare ASC
  5. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - UHC Medicare Profees7 base · 19 adj
United Healthcare Medicare
Profee · NY · 2024-09-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
  6. 100% of Medicare RVU
  7. 35% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - UHC Medicare Profees (pre 9.1.24)3 base · 19 adj
United Healthcare Medicare
Profee · NY · 2023-01-01 → 2024-08-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-UHC-Profee-Fees fee schedule
  3. 35% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - UHC Profees (Pre 9.1.2024)27 base · 18 adj
UHC Oxford/Freedom, UHC Oxford/Liberty, UHC Oxford/Metro, UHC/Compass/Navigate/Core, United Healthcare Commercial
Profee · NY · 2023-01-01 → 2024-08-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  4. 100% of the UHC-Medicare-Multiplier fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  7. 100% of the UHC-Medicare-Multiplier fee schedule
  8. Multiply 100% of Medicare DME (NY, rates as of 2020-01-01)
  9. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (NY, rates as of 2020-01-01)
  12. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is present
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  15. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  16. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  17. Multiply 100% of Medicare drug
  18. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  19. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  20. Multiply 100% of Medicare DME (NY, rates as of 2020-01-01)
  21. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  22. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  23. Multiply 100% of Medicare lab (NY, rates as of 2020-01-01)
  24. computed expression (operands follow) — when UHCPhysicianStatus MD/DO is absent
  25. 100% of the UHC-Medicare-Multiplier-Non-Physician fee schedule
  26. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  27. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 55 present → 20% 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
NY - United Healthcare Empire Facility Fees3 base · 19 adj
Empire NYShip
Facility · NY · 2024-11-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC (rates as of 2023-12-01)
  3. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/0%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Wellcare Profees 20236 base · 19 adj
Wellcare
Profee · NY · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. computed expression (operands follow)
  4. 100% of the NY-Wellcare-Profee-Fees fee schedule
  5. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  6. Multiply 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Wellcare Profees 202410 base · 19 adj
Wellcare
Profee · NY · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug — when NYNMNewProvider New is present ⚠︎ named “106% Medicare ASP Drug (2024 New Providers Only)” but configured at 100%
  3. 75% of Medicare DME — when NYNMNewProvider New is present
  4. 50% of Medicare lab — when NYNMNewProvider New is present
  5. 100% of Medicare RVU — when NYNMNewProvider New is present
    • CodeRange 70000–79999 → 85%
    • CodeRange 97165–97168 → 80%
    • CodeRange 92507–92508 → 80%
    • CodeRange 92521–92523 → 80%
    • CodeRange 97110–97546 → 80%
    • CodeRange 00000–99999 → 85%
    • CodeRange AAAAA–ZZZZZ → 85%
  6. 100% of Medicare drug
  7. computed expression (operands follow)
  8. 100% of the NY-Wellcare-Profee-Fees fee schedule
  9. Divide 100% of Medicare RVU (rates as of 2025-01-01)
  10. Multiply 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Wellcare Profees 20255 base · 19 adj
Wellcare
Profee · NY · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug ⚠︎ named “106% Medicare ASP Drug” but configured at 100%
  3. 75% of Medicare DME
  4. 50% of Medicare lab
  5. 100% of Medicare RVU
    • CodeRange 70000–79999 → 85%
    • CodeRange 97165–97168 → 80%
    • CodeRange 92507–92508 → 80%
    • CodeRange 92521–92523 → 80%
    • CodeRange 97110–97546 → 80%
    • CodeRange 00000–99999 → 85%
    • CodeRange AAAAA–ZZZZZ → 85%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY Medicaid5 base · 19 adj
NY Medicaid
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-Medicaid-Drug-Fixed-Fees fee schedule
  3. 100% of the NY-Medicaid-Surgery-Fixed-Fees fee schedule
  4. 100% of the NY-Medicaid-Radiology-Fixed-Fees fee schedule
  5. 100% of the NY-Medicaid-Medical-Services-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY-UHC Commercial Facility Fees (11.1.24)3 base · 19 adj
United Healthcare Commercial
Facility · NY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC (rates as of 2023-01-01)
  3. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/0%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Aetna Commercial Facility Fees (PSI & PLSI)4 base · 19 adj
Aetna Commercial Plans
Facility · 2 named facilities · 2023-07-15 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. case rate from CaseRate (All-level codes)
  4. flat $0 — when Aetna Noncovered Facility Charge Noncovered is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Aetna Commercial Profees3 base · 19 adj
Aetna Commercial Plans
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the PA-Aetna-Facility-Profees fee schedule — when FacilityType in ASC, Hospital
    • CodeRange 60117–60118 → 105%
    • CodeRange 65222–65222 → 110%
    • CodeRange 65400–65400 → 110%
    • CodeRange 67311–67312 → 110%
    • CodeRange 67331–67332 → 110%
    • CodeRange 67334–67335 → 110%
    • CodeRange 67412–67412 → 110%
    • CodeRange 67820–67820 → 110%
    • CodeRange 68440–68440 → 110%
    • CodeRange 68761–68761 → 110%
    • CodeRange 68811–68811 → 110%
    • CodeRange 68815–68815 → 110%
    • CodeRange 68840–68840 → 110%
    • CodeRange 92002–92019 → 106%
    • CodeRange 99202–99245 → 106%
    • CodeRange 99252–99285 → 116%
    • CodeRange 90281–91317 → 116%
    • CodeRange 92020–99199 → 116%
  3. 100% of the PA-Aetna-Clinic-Profees fee schedule
    • CodeRange 60117–60118 → 105%
    • CodeRange 65222–65222 → 110%
    • CodeRange 65400–65400 → 110%
    • CodeRange 67311–67312 → 110%
    • CodeRange 67331–67332 → 110%
    • CodeRange 67334–67335 → 110%
    • CodeRange 67412–67412 → 110%
    • CodeRange 67820–67820 → 110%
    • CodeRange 68440–68440 → 110%
    • CodeRange 68761–68761 → 110%
    • CodeRange 68811–68811 → 110%
    • CodeRange 68815–68815 → 110%
    • CodeRange 68840–68840 → 110%
    • CodeRange 92002–92019 → 106%
    • CodeRange 99202–99245 → 106%
    • CodeRange 99252–99285 → 116%
    • CodeRange 90281–91317 → 116%
    • CodeRange 92020–99199 → 116%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Aetna Medicare Facility Fees (PSI & PLSI)4 base · 19 adj
Aetna Medicare Plans
Facility · 2 named facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC
  3. 100% of Medicare ASC
  4. 35% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Aetna Medicare Profees3 base · 19 adj
Aetna Medicare Plans
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the PA-Aetna-Facility-Profees fee schedule — when FacilityType in ASC, Hospital
    • CodeRange 60117–60118 → 105%
    • CodeRange 65222–65222 → 110%
    • CodeRange 65400–65400 → 110%
    • CodeRange 67311–67312 → 110%
    • CodeRange 67331–67332 → 110%
    • CodeRange 67334–67335 → 110%
    • CodeRange 67412–67412 → 110%
    • CodeRange 67820–67820 → 110%
    • CodeRange 68440–68440 → 110%
    • CodeRange 68761–68761 → 110%
    • CodeRange 68811–68811 → 110%
    • CodeRange 68815–68815 → 110%
    • CodeRange 68840–68840 → 110%
    • CodeRange 92002–92019 → 106%
    • CodeRange 99202–99245 → 106%
    • CodeRange 99252–99285 → 116%
    • CodeRange 90281–91317 → 116%
    • CodeRange 92020–99199 → 116%
  3. 100% of the PA-Aetna-Clinic-Profees fee schedule
    • CodeRange 60117–60118 → 105%
    • CodeRange 65222–65222 → 110%
    • CodeRange 65400–65400 → 110%
    • CodeRange 67311–67312 → 110%
    • CodeRange 67331–67332 → 110%
    • CodeRange 67334–67335 → 110%
    • CodeRange 67412–67412 → 110%
    • CodeRange 67820–67820 → 110%
    • CodeRange 68440–68440 → 110%
    • CodeRange 68761–68761 → 110%
    • CodeRange 68811–68811 → 110%
    • CodeRange 68815–68815 → 110%
    • CodeRange 68840–68840 → 110%
    • CodeRange 92002–92019 → 106%
    • CodeRange 99202–99245 → 106%
    • CodeRange 99252–99285 → 116%
    • CodeRange 90281–91317 → 116%
    • CodeRange 92020–99199 → 116%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Amerihealth Profees2 base · 19 adj
Amerihealth
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - BCBS Highmark Facility Fees PLSI 20232 base · 19 adj
BCBS Highmark
Facility · 1 named facilities · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 140% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - BCBS Highmark Facility Fees PLSI 20242 base · 19 adj
BCBS Highmark
Facility · 1 named facilities · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 143% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - BCBS Highmark Facility Fees PLSI 20252 base · 19 adj
BCBS Highmark
Facility · 1 named facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 146% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - BCBS Highmark Facility Fees PSI 20232 base · 19 adj
BCBS Highmark
Facility · 1 named facilities · 2023-01-01 → 2023-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 144% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - BCBS Highmark Facility Fees PSI 20242 base · 19 adj
BCBS Highmark
Facility · 1 named facilities · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 145% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - BCBS Highmark Facility Fees PSI 20252 base · 19 adj
BCBS Highmark
Facility · 1 named facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 146% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Capital BC Commercial Facility3 base · 19 adj
Capital Advantage Commercial, Capital Blue Cross Commercial
Facility · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the PA-Capital BlueCross-Groupers fee schedule
  3. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-radiology reduction — base codes 4
  3. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Envolve Profees2 base · 19 adj
Envolved
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Geisinger Commercial Facility Fees2 base · 19 adj
Geisinger Health Commercial Plans
Facility · PA · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 102% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Geisinger Commercial Profees3 base · 19 adj
Geisinger Health Commercial Plans
Profee · PA · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 106% of the PA-Geisinger-Facility-Profees fee schedule — when FacilityType in ASC
  3. 106% of the PA-Geisinger-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Geisinger MA Profees (6.19.23 to 6.18.24)2 base · 19 adj
Geisinger Health Medicare Plans
Profee · PA · 2023-06-19 → 2024-06-18
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 102% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Geisinger MA Profees (6.19.24 onwards)3 base · 19 adj
Geisinger Health Medicare Plans
Profee · PA · 2024-06-19 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 104% of the PA-Geisinger-MA-Facility-Profees fee schedule — when FacilityType in ASC
  3. 104% of the PA-Geisinger-MA-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Highmark Commercial Profees3 base · 19 adj
BCBS Highmark
Profee · PA · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the PA-Highmark-Facility-Profees fee schedule — when FacilityType in ASC, Hospital
  3. 100% of the PA-Highmark-Clinic-Profees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Highmark Wholecare Medicaid Profees3 base · 19 adj
Highmark Wholecare Medicaid
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the PA-Medicaid-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital
  3. 100% of the PA-Medicaid-Clinic-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Humana Medicare Profees4 base · 19 adj
Humana Medicare
Profee · PA · 2023-06-13 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. 85% of the Profee-Fees fee schedule — when CPTCategory Pathology & Laboratory is present
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Jefferson Health Plans Profees5 base · 19 adj
Jefferson Health Plans
Profee · Progressive Laser Surgical Institute, Progressive Surgical Institute, Progressive Vision Institute, Progressive Vision Institute of Allentown, Progressive Vision Institute of Philadelphia · 2024-01-01 → 2024-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid 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-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Jefferson Health Plans Profees (1.1.2025)5 base · 19 adj
Jefferson Health Plans
Profee · Progressive Laser Surgical Institute, Progressive Surgical Institute, Progressive Vision Institute, Progressive Vision Institute of Allentown, Progressive Vision Institute of Philadelphia · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 115% of Medicare lab
  3. 115% of Medicare drug
  4. 115% of Medicare DME
  5. 115% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - Medicaid Profees3 base · 19 adj
PA Medicaid
Profee · PA · 2023-01-01 → 2999-12-31
Geisinger Health Medicaid Plans
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the PA-Medicaid-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital
  3. 100% of the PA-Medicaid-Clinic-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - UHC Commercial Profees15 base · 19 adj
United Healthcare Commercial
Profee · PA · 2024-09-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Carveouts fee schedule
  3. computed expression (operands follow)
  4. 100% of the UHC-Medicare-Multiplier fee schedule
  5. Multiply 100% of Medicare drug
  6. computed expression (operands follow)
  7. 100% of the UHC-Medicare-Multiplier fee schedule
  8. Multiply 100% of Medicare DME (PA, rates as of 2019-01-01)
  9. computed expression (operands follow)
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (PA, rates as of 2019-01-01)
  12. computed expression (operands follow)
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2019-01-01)
  15. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 55 present → 20% 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. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
PA - UPMC Commercial Profees (10.1.2023)5 base · 19 adj
UPMC
Profee · PA · 2024-04-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 123% of Medicare drug
  3. 100% of the Profee-Fees fee schedule
  4. 123% of Medicare RVU
  5. 70% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - UPMC Medicaid Profees4 base · 19 adj
UPMC Medicaid
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare drug
  3. 115% of the PA-Medicaid-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Hospital
  4. 115% of the PA-Medicaid-Clinic-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - UPMC Medicare Profees5 base · 19 adj
UPMC Medicare
Profee · PA · 2023-10-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 106% of Medicare lab
  3. 100% of Medicare drug
  4. 106% of Medicare DME
  5. 106% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA-Highmark Medicare Profees5 base · 19 adj
BCBS Highmark Medicare
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid 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-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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

Cannot fire (11)

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

90% Medicare ASC Rates · no contract map4 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 90% of Medicare ASC
  3. 90% of Medicare ASC — when FacilityState in NY
  4. 90% of Medicare ASC — when FacilityState in NJ
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Aetna Commercial Profees (9.1.23 onwards) · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the NY-Aetna-Profee-Fees fee schedule — when FacilityType in Clinic, Clinical
  3. 100% of the NY-Aetna-Facility-Profee-Fees fee schedule — when FacilityType in ASC, Surgical
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Aetna Commercial Profees-Copy · no contract map8 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. flat $1089 — when ProcedureCode 66984 is present
  3. 100% of Medicare lab (rates as of 2018-12-01) — when Aetna2018MedicareCodes 2018medicare is present ⚠︎ named “57% of 2018 Medicare Laboratory/Pathology” but configured at 100%
  4. 100% of Medicare RVU (rates as of 2018-12-01) — when Aetna2018MedicareCodes 2018medicare is present
  5. 100% of Medicare DME
  6. 100% of Medicare drug
  7. 114% of Medicare RVU ⚠︎ named “100% Current Year Medicare RVU Fallback” but configured at 114%
  8. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Fidelis Plus Profees · no contract map5 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 84% of Medicare lab
  3. 84% of Medicare drug
  4. 84% of Medicare DME
  5. 84% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Fidelis Profees · no contract map5 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 83% of Medicare lab
  3. 83% of Medicare drug
  4. 83% of Medicare DME
  5. 83% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - GHI Profees · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. custom SQL — The NY GHI portion of a combined GHI/HIP master rate table: a locality- and place-of-service-specific fee for a procedure/modifier, using the most recently effective rate as of the service date.
  3. 84.91% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - HIP Profees · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. custom SQL — The NY HIP counterpart to c91447a37b433cb5 -- identical locality/POS-based rate lookup against the same master table, reading the HIPLocality1/HIPLocality2 columns instead of GHILocality1/GHILocality2.
  3. 84.91% of Medicare drug
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - UHC Commercial Facility Fees · no contract map2 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Grouper-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50/25/0%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
NY - Wellcare Profees · no contract map6 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 50% of Medicare lab
  3. 100% of Medicare drug
  4. 75% of Medicare DME
  5. 100% of Medicare RVU — when CPTCategory Radiology is present ⚠︎ named “85% of Medicare RVU Radiology Codes” but configured at 100%
  6. 85% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - BCBS Capital Advantage Commercial Facility · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of Medicare ASC
  3. 65% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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
PA - UPMC Profees · no contract map2 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $0 — when NonValidProcedureCode Non-Valid is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  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. modifier 54 present → 80% of the running amount
  9. modifier 55 present → 20% of the running amount
  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