Customer detail

Commonwealth

42
live contracts
37
cannot fire
21
calc types
2
SQL bodies
0
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment1,005
MedicareRVU161
PercentOfFees155
MedicareMultipleProcedureAdjustment77
LesserOfAdjustment77
MedicareMultipleEndoscopyAdjustment77
MedicareMultipleRadiologyAdjustment77
MidLevelProviderAdjustment59
MedicareDrug52
MedicareLab40
MedicareAnesthesia26
FlatPercentOfCharges21
MedicareDME21
MedicareMultipleTherapyAdjustment16
CalculationBuilder13
MedicareBilateralSurgeryAdjustment8
FlatPercentageAdjustment6
ExcludedChargeAdjustment6
MedicareASC4
SqlExpression4
PercentOfCharges2

Contracts

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

Aetna Better Health KY Profees5 base · 18 adj
Aetna Better Health KY
Profee · CPS KY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 45% of billed charges — when KYMedicaidBCCode 1 is present
  3. 68% of the Fixed-Fees-Labs fee schedule
  4. 100% of Medicare drug ⚠︎ named “106% of Medicare ASP Drug Rates” but configured at 100%
  5. 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 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
Aetna Commercial IN4 base · 18 adj
Aetna
Profee · CPS IN · 2024-09-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 111% of the Fixed-Fees fee schedule — when TriggerPointInjections INJ; SINGLE/MX TRIG POINT is present
  3. 111% of the Fixed-Fees fee schedule — when OfficeOutpatient Office/Outpatient Visits is present
  4. 100% of the Fixed-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) — when MidLevelCPTExclusions Exclude is absent
  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 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
Aetna Commercial KY Profee4 base · 18 adj
Aetna
Profee · CPS KY · 2018-03-01 → 2025-08-14
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 111% of the Fixed-Fees fee schedule — when TriggerPointInjections INJ; SINGLE/MX TRIG POINT is present
  3. 111% of the Fixed-Fees fee schedule — when OfficeOutpatient Office/Outpatient Visits is present
  4. 100% of the Fixed-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) — when MidLevelCPTExclusions Exclude is absent
  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 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
Aetna Commercial KY Profee 20254 base · 18 adj
Aetna
Profee · CPS KY · 2025-08-15 → 2026-08-14
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 128% of the Fixed-Fees fee schedule — when TriggerPointInjections INJ; SINGLE/MX TRIG POINT is present
  3. 128% of the Fixed-Fees fee schedule — when OfficeOutpatient Office/Outpatient Visits is present
  4. 110% of the Fixed-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) — when MidLevelCPTExclusions Exclude is absent
  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 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
Aetna Commercial KY Profee 20264 base · 18 adj
Aetna
Profee · CPS KY · 2026-08-15 → 2027-08-14
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 131% of the Fixed-Fees fee schedule — when TriggerPointInjections INJ; SINGLE/MX TRIG POINT is present
  3. 131% of the Fixed-Fees fee schedule — when OfficeOutpatient Office/Outpatient Visits is present
  4. 115% of the Fixed-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) — when MidLevelCPTExclusions Exclude is absent
  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 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
Aetna Commercial KY Profee 20274 base · 18 adj
Aetna
Profee · CPS KY · 2027-08-15 → 2028-08-14
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 135% of the Fixed-Fees fee schedule — when TriggerPointInjections INJ; SINGLE/MX TRIG POINT is present
  3. 135% of the Fixed-Fees fee schedule — when OfficeOutpatient Office/Outpatient Visits is present
  4. 120% of the Fixed-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) — when MidLevelCPTExclusions Exclude is absent
  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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem BCBS NC - Profees2 base · 20 adj
Anthem BCBS Commercial IL, Anthem BCBS Commercial IN, Anthem BCBS Commercial KY, Anthem BCBS Commercial NC, Anthem BCBS Commercial OH, Anthem BCBS Commercial Other Plans, Anthem BCBS Commercial SC, Anthem BCBS Commercial TN
Profee · CPS NC, Clinic · 2025-03-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Fees fee schedule
  2. 75% 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. Medicare bilateral-surgery adjustment — when Modifier 50 is absent
  6. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Anthem BCBS SC - Profees2 base · 20 adj
Anthem BCBS Commercial IL, Anthem BCBS Commercial IN, Anthem BCBS Commercial KY, Anthem BCBS Commercial NC, Anthem BCBS Commercial OH, Anthem BCBS Commercial Other Plans, Anthem BCBS Commercial SC, Anthem BCBS Commercial TN
Profee · CPS SC · 2025-02-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Drugs fee schedule
  2. 100% of the Fixed-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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. Medicare bilateral-surgery adjustment — when Modifier 50 is absent
  6. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Anthem BCBS TN - Profees7 base · 20 adj
Anthem BCBS Commercial IL, Anthem BCBS Commercial IN, Anthem BCBS Commercial KY, Anthem BCBS Commercial NC, Anthem BCBS Commercial OH, Anthem BCBS Commercial Other Plans, Anthem BCBS Commercial SC, Anthem BCBS Commercial TN
Profee · CPS TN · 2024-09-20 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia — when BCBSTNNetworkType S is present
  2. 100% of Medicare anesthesia — when BCBSTNNetworkType S is absent
  3. 52% of Medicare lab (rates as of 2021-01-01)
  4. 75% of Medicare DME
  5. 100% of Medicare drug ⚠︎ named “106% of Current-Year ASP” but configured at 100%
  6. 100% of Medicare RVU (rates as of 2021-01-01) — when BCBSTNNetworkType S is present
    • CodeRange 20100–29999 → 100%
    • CodeRange 33016–37799 → 100%
    • CodeRange 61000–64999 → 100%
    • CodeRange 10000–69999 → 96%
    • CodeRange 70000–79999 → 77%
    • CodeRange 80000–89999 → 52%
    • CodeRange 99381–99397 → 92%
    • CodeRange 92920–93799 → 102%
    • CodeRange 98940–98943 → 79%
    • CodeRange 95700–96020 → 102%
    • CodeRange 97010–97799 → 67%
    • CodeRange 94010–94799 → 102%
    • CodeRange 99202–99499 → 88%
    • CodeRange 90000–99999 → 85%
  7. 100% of Medicare RVU (rates as of 2021-01-01) — when BCBSTNNetworkType S is absent
    • CodeRange 20100–29999 → 108%
    • CodeRange 33016–37799 → 108%
    • CodeRange 61000–64999 → 108%
    • CodeRange 10000–69999 → 104%
    • CodeRange 70000–79999 → 85%
    • CodeRange 80000–89999 → 52%
    • CodeRange 99381–99397 → 100%
    • CodeRange 92920–93799 → 110%
    • CodeRange 98940–98943 → 87%
    • CodeRange 95700–96020 → 110%
    • CodeRange 97010–97799 → 75%
    • CodeRange 94010–94799 → 110%
    • CodeRange 99202–99499 → 96%
    • CodeRange 90000–99999 → 93%
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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. Medicare bilateral-surgery adjustment — when Modifier 50 is absent
  6. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Anthem BCBS TN Medicaid - Profees2 base · 20 adj
Anthem Medicaid
Profee · CPS TN · 2024-09-20 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. Medicare bilateral-surgery adjustment — when Modifier 50 is absent
  6. mid-level provider reduction (by NUCC taxonomy) — when MidLevelCPTExclusions Exclude is absent
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier AS present → 14% of the running amount
  17. modifier QY present → 50% of the running amount
  18. modifier QK present → 50% of the running amount
  19. modifier QX present → 50% of the running amount
  20. cap each charge and the account total at 100% of billed charges
Anthem Commercial KY-Clinic Profees3 base · 22 adj
Anthem BCBS Commercial IL, Anthem BCBS Commercial IN, Anthem BCBS Commercial KY, Anthem BCBS Commercial NC, Anthem BCBS Commercial OH, Anthem BCBS Commercial Other Plans, Anthem BCBS Commercial SC, Anthem BCBS Commercial TN
Profee · CPS IN, CPS KY, CPS OH, Clinic · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Looks up an anesthesia fee (CPT 00100-01999) directly from the customer's own Profee-Fees schedule by insurance, facility, and date, intentionally without multiplying by units (anesthesia units are handled elsewhere in the pricing chain). — when CPTCategory Anesthesia is present
  2. 100% of the Carveouts fee schedule
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. zero out charges excluded by the Bundled-Procedure-Codes schedule
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  6. Medicare bilateral-surgery adjustment — when Modifier 50 is absent
  7. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  8. modifier 22 present → 135% of the running amount
  9. modifier 50 present → 150% of the running amount
  10. modifier 52 present → 50% of the running amount
  11. modifier 54 present → 80% of the running amount
  12. modifier 62 present → 62.5% of the running amount
  13. modifier 78 present → 70% of the running amount
  14. modifier 80 present → 16% of the running amount
  15. modifier 81 present → 16% of the running amount
  16. modifier 82 present → 16% of the running amount
  17. modifier 95 present → 85% of the running amount
  18. modifier AS present → 14% of the running amount
  19. modifier QY present → 50% of the running amount
  20. modifier QK present → 50% of the running amount
  21. modifier QX present → 50% of the running amount
  22. cap each charge and the account total at 100% of billed charges
Anthem Commercial KY-Facility Profees2 base · 21 adj
Anthem BCBS Commercial IL, Anthem BCBS Commercial IN, Anthem BCBS Commercial KY, Anthem BCBS Commercial NC, Anthem BCBS Commercial OH, Anthem BCBS Commercial Other Plans, Anthem BCBS Commercial SC, Anthem BCBS Commercial TN
Profee · CPS IN, CPS KY, CPS OH, ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Looks up an anesthesia fee (CPT 00100-01999) directly from the customer's own Profee-Fees schedule by insurance, facility, and date, intentionally without multiplying by units (anesthesia units are handled elsewhere in the pricing chain). — when CPTCategory Anesthesia is present
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. zero out charges excluded by the Bundled-Procedure-Codes schedule
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. Medicare bilateral-surgery adjustment — when Modifier 50 is absent
  6. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  7. modifier 22 present → 135% of the running amount
  8. modifier 50 present → 150% of the running amount
  9. modifier 52 present → 50% of the running amount
  10. modifier 54 present → 80% of the running amount
  11. modifier 62 present → 62.5% of the running amount
  12. modifier 78 present → 70% of the running amount
  13. modifier 80 present → 16% of the running amount
  14. modifier 81 present → 16% of the running amount
  15. modifier 82 present → 16% of the running amount
  16. modifier 95 present → 85% of the running amount
  17. modifier AS present → 14% of the running amount
  18. modifier QY present → 50% of the running amount
  19. modifier QK present → 50% of the running amount
  20. modifier QX present → 50% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Anthem IN Medicaid Profees5 base · 18 adj
Anthem IN Medicaid
Profee · CPS IN · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare RVU ⚠︎ named “130% IN Medicare Fee Schedule” but configured at 100%
  2. percent-of-charges, rate read from the Percent of Charges schedule
  3. 130% of the Fixed-Fees fee schedule
  4. 130% of the Profee-Fees fee schedule
  5. 0% 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. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy) — when MidLevelCPTExclusions Exclude is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem Pathway Clinic Profees3 base · 19 adj
Anthem Pathway
Profee · CPS KY, Clinic · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Same anesthesia fee-schedule lookup as hash 32ee8a4e62693e0d, but hardcodes the payer to 'Anthem BCBS Commercial KY' as a workaround because the real Anthem Pathway schedule doesn't carry anesthesia rates. — when CPTCategory Anesthesia is present
  2. 100% of Medicare drug
  3. 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Anthem Pathway Facility Profees3 base · 18 adj
Anthem Pathway
Profee · CPS KY, ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Same anesthesia fee-schedule lookup as hash 32ee8a4e62693e0d, but hardcodes the payer to 'Anthem BCBS Commercial KY' as a workaround because the real Anthem Pathway schedule doesn't carry anesthesia rates. — when CPTCategory Anesthesia is present
  2. 100% of Medicare drug
  3. 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) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  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 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
Charges1 base · 0 adj
Charges
Facility, Profee · all facilities · 2018-09-05 → 2999-12-31
Base terms — first match wins
  1. 100% of the Charges fee schedule
Cigna KY4 base · 17 adj
Cigna
Profee · CPS KY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the MD-Profee-Fees fee schedule — when ProviderType MD is present
  2. 100% of the MidLevel-Profee-Fees fee schedule
  3. 100% of Medicare drug — when CodeRange in J0000–J9999; CodeRange in J0000–J9999
  4. 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. 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Cigna NC SC - Profees2 base · 17 adj
Cigna
Profee · CPS NC, CPS SC · 2025-03-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the MD-Profee-Fees fee schedule
  2. 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. 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Humana Commercial9 base · 18 adj
Humana Commercial
Profee · CPS KY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 145% of the Profee-Fees fee schedule — when CPTCategory Evaluation & Management is present; ProviderType MD is present
  3. 105% of the Profee-Fees fee schedule — when CPTCategory Evaluation & Management is present
  4. 100% of Medicare drug
  5. 106% of the Profee-Fees fee schedule — when CPTCategory Pathology & Laboratory is present
  6. 75% of the Profee-Fees fee schedule — when CPTCategory V-Codes is present
  7. 106% of the Fixed-Fees-Radiology fee schedule — when CPTCategory Radiology is present
  8. 96% of the Fixed-Fees fee schedule — when ProviderType MD is absent
  9. 106% of the Fixed-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 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
Humana Medicaid5 base · 18 adj
Humana Medicaid
Profee · CPS KY · 2023-01-01 → 2025-04-30
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of the Anesthesia-Custom fee schedule
  3. 60% of the Fixed-Fees-Labs fee schedule
  4. 101% of the Profee-Fees fee schedule
  5. 100% 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) — when MidLevelCPTExclusions Exclude is absent
  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 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
Humana Medicare20 base · 17 adj
Humana Medicare, Humana Medicare Dual
Profee · CPS KY · 2023-01-01 → 2025-04-30
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 95% of Medicare anesthesia
  3. 100% of Medicare drug
  4. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  5. 80% of Medicare RVU — when CPTCategory Radiology is present
  6. 75% of Medicare RVU — when CPTCategory E-Codes is present
  7. 75% of Medicare RVU — when CPTCategory G-Codes is present; Modifier 95 is present
  8. 75% of Medicare RVU — when CPTCategory G-Codes is present
  9. 75% of Medicare RVU — when CPTCategory H-Codes is present
  10. 75% of Medicare RVU — when CPTCategory L-Codes is present
  11. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  12. 75% of Medicare RVU — when CPTCategory S-Codes is present
  13. 80% of Medicare RVU — when CPTCategory V-Codes is present
  14. 95% of Medicare RVU — when ProviderType MD is present; Modifier 95 is present
  15. 95% of Medicare RVU — when ProviderType MD is present
  16. 95% of Medicare RVU — when ProviderType DO is present; Modifier 95 is present
  17. 95% of Medicare RVU — when ProviderType DO is present
  18. 76% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent; Modifier 95 is present
  19. 76% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent
  20. 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. 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Humana Medicare OON6 base · 19 adj
Humana Medicare, Humana Medicare Dual
Profee · CPS KY · 2025-05-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when Modifier 95 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 — base codes 4
  4. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when Modifier QZ is absent; Modifier QX is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
IL Medicaid - Profees3 base · 17 adj
IL Medicaid
Profee · CPS IL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-DME fee schedule
  2. 100% of the Fixed-Fees-Labs fee schedule
  3. 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. 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
IN Medicaid Profees4 base · 18 adj
Managed Health Services
Profee · CPS IN · 2024-01-01 → 2999-12-31
Caresource Indiana Medicaid
Profee · CPS IN · 2024-01-01 → 2999-12-31
Humana Medicaid
Profee · CPS IN · 2024-01-01 → 2999-12-31
United Healthcare Medicaid
Profee · CPS IN · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. percent-of-charges, rate read from the Percent of Charges schedule
  2. 100% of the Fixed-Fees fee schedule
  3. 100% of the Profee-Fees fee schedule
  4. 0% 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. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy) — when MidLevelCPTExclusions Exclude is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
KY Medicaid - Profees5 base · 18 adj
Anthem Medicaid
Profee · CPS KY · 2023-01-01 → 2999-12-31
United Healthcare Medicaid
Profee · CPS KY · 2023-01-01 → 2999-12-31
KY Medicaid
Profee · CPS KY · 2023-01-01 → 2999-12-31
Humana Medicaid
Profee · CPS KY · 2025-05-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 45% of billed charges — when KYMedicaidBCCode 1 is present
  3. 100% of the Fixed-Fees-Labs fee schedule
  4. 100% of the Profee-Fees fee schedule
  5. 100% 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 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
MDWise Profees1 base · 18 adj
MDWise
Profee · CPS IN, CPS KY · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 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) — when MidLevelCPTExclusions Exclude is absent
  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 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
Medicare6 base · 21 adj
Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
Aetna Medicare, Aetna Medicare Dual
Profee · CPS IN, CPS KY · 2023-01-01 → 2999-12-31
Anthem Medicare, Anthem Medicare Dual
Profee · CPS IN, CPS KY, CPS OH · 2023-01-01 → 2999-12-31
Cigna Medicare, Cigna Medicare Dual
Profee · all facilities · 2023-01-01 → 2999-12-31
WellCare Medicare, WellCare Medicare Dual
Profee · CPS SC · 2023-01-01 → 2999-12-31
WellCare Medicare, WellCare Medicare Dual
Profee · CPS KY · 2023-01-01 → 2999-12-31
Passport Medicare, Passport Medicare Dual
Profee · all facilities · 2023-01-01 → 2999-12-31
United Healthcare Medicare, United Healthcare Medicare Dual
Profee · CPS IN · 2023-01-01 → 2999-12-31
VA CCN
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU — when Modifier 95 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 — base codes 4
  4. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when Modifier QZ is absent; Modifier QX is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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 GY present → 0% of the running amount
  20. modifier GZ present → 0% of the running amount
  21. cap each charge and the account total at 100% of billed charges
Medicare-ASC1 base · 18 adj
Medicare
Facility · ASC, Hospital · 2023-01-01 → 2999-12-31
Aetna Medicare, Aetna Medicare Dual
Facility · CPS KY, ASC, Hospital · 2023-01-01 → 2999-12-31
Anthem Medicare, Anthem Medicare Dual
Facility · CPS KY, ASC, Hospital · 2023-01-01 → 2999-12-31
United Healthcare Medicare, United Healthcare Medicare Dual
Facility · CPS IN, ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  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 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
NC Medicaid - Profees3 base · 18 adj
NC Medicaid
Profee · CPS NC · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-DME fee schedule
  2. 100% of the Fixed-Fees-Labs fee schedule
  3. 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) — when MidLevelCPTExclusions Exclude is absent
  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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
OH Medicaid - Profees9 base · 18 adj
OH Medicaid
Profee · CPS OH · 2024-01-01 → 2999-12-31
Aetna Better Health OH
Profee · CPS OH · 2024-01-01 → 2999-12-31
Anthem Medicaid
Profee · CPS OH · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 50% of Medicare anesthesia — when Modifier QX is present
  2. 50% of Medicare anesthesia — when Modifier QY is present
  3. 50% of Medicare anesthesia — when Modifier QK is present
  4. 300% of Medicare anesthesia — when Modifier AD is present
  5. 100% of Medicare anesthesia
  6. 100% of the Fixed-Fees-DME fee schedule
  7. 100% of the Fixed-Fees-Drugs fee schedule
  8. 100% of the Fixed-Fees-Labs fee schedule
  9. 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 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
Passport Medicaid5 base · 18 adj
Passport Medicaid
Profee · CPS KY · 2019-01-01 → 2999-12-31
Base terms — first match wins
  1. 80% of Medicare anesthesia
  2. 80% of Medicare lab
  3. 100% of Medicare drug
  4. 80% of Medicare RVU
  5. 25% 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 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
SC Medicaid - Profees5 base · 18 adj
SC Medicaid
Profee · CPS SC · 2024-07-01 → 2999-12-31
WellCare Medicaid
Profee · CPS SC · 2024-07-01 → 2999-12-31
Humana Medicaid
Profee · CPS SC · 2024-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. 100% of the Fixed-Fees-DME fee schedule
  4. 100% of the Fixed-Fees-Labs fee schedule
  5. 100% of the Fixed-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) — when MidLevelCPTExclusions Exclude is absent
  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 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
UHC Commercial 2024-0915 base · 19 adj
United Healthcare Commercial
Profee · CPS IN, CPS KY · 2024-09-01 → 2025-09-30
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare anesthesia
  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 (KY, rates as of 2019-12-01)
  9. computed expression (operands follow)
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (KY, rates as of 2019-12-01)
  12. computed expression (operands follow)
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2019-12-01)
  15. 50% of billed charges
Adjustments — all apply, in order
  1. zero out charges excluded by the Bundled-Procedure-Codes schedule
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode 99203 is absent; ProcedureCode 99204 is absent; ProcedureCode 99213 is absent; ProcedureCode 99214 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
UHC Commercial 2025-1015 base · 20 adj
United Healthcare Commercial
Profee · CPS IN, CPS KY · 2025-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare anesthesia
  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 (KY, rates as of 2019-12-01)
  9. computed expression (operands follow)
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (KY, rates as of 2019-12-01)
  12. computed expression (operands follow)
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2019-12-01)
  15. 50% of billed charges
Adjustments — all apply, in order
  1. zero out charges excluded by the Bundled-Procedure-Codes schedule
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode 99203 is absent; ProcedureCode 99204 is absent; ProcedureCode 99213 is absent; ProcedureCode 99214 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
UHC Commercial ASC5 base · 18 adj
United Healthcare Commercial
Facility · CPS IN, CPS KY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. computed expression (operands follow)
  3. 100% of the UHC-Medicare-Multiplier fee schedule
  4. Multiply 100% of Medicare ASC (rates as of 2019-12-01)
  5. 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 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
UHC Commercial KY15 base · 18 adj
United Healthcare Commercial
Profee · CPS IN, CPS KY · 2023-01-01 → 2024-08-31
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare anesthesia
  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 (KY, rates as of 2019-12-01)
  9. computed expression (operands follow)
  10. 100% of the UHC-Medicare-Multiplier fee schedule
  11. Multiply 100% of Medicare lab (KY, rates as of 2019-12-01)
  12. computed expression (operands follow)
  13. 100% of the UHC-Medicare-Multiplier fee schedule
  14. Multiply 100% of Medicare RVU (rates as of 2019-12-01)
  15. 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) — when ProcedureCode 99203 is absent; ProcedureCode 99204 is absent; ProcedureCode 99213 is absent; ProcedureCode 99214 is absent
  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 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
UHC Commercial TN8 base · 19 adj
United Healthcare Commercial
Profee · CPS TN · 2025-04-01 → 2025-09-30
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare anesthesia
  3. 100% of Medicare drug
  4. 60% of Medicare DME (rates as of 2020-01-01)
  5. 60% of Medicare lab (rates as of 2020-01-01) — when FacilityType Clinic is present
  6. 42% of Medicare lab (rates as of 2020-01-01) — when FacilityType Clinic is absent
  7. 100% of Medicare RVU (rates as of 2020-01-01)
  8. 40% of billed charges
Adjustments — all apply, in order
  1. zero out charges excluded by the Bundled-Procedure-Codes schedule
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode 99203 is absent; ProcedureCode 99204 is absent; ProcedureCode 99213 is absent; ProcedureCode 99214 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
UHC Commercial TN 2025-108 base · 20 adj
United Healthcare Commercial
Profee · CPS TN · 2025-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare anesthesia
  3. 100% of Medicare drug
  4. 60% of Medicare DME (rates as of 2020-01-01)
  5. 60% of Medicare lab (rates as of 2020-01-01) — when FacilityType Clinic is present
  6. 42% of Medicare lab (rates as of 2020-01-01) — when FacilityType Clinic is absent
  7. 100% of Medicare RVU (rates as of 2020-01-01)
  8. 40% of billed charges
Adjustments — all apply, in order
  1. zero out charges excluded by the Bundled-Procedure-Codes schedule
  2. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  3. Medicare multiple-endoscopy reduction
  4. Medicare multiple-radiology reduction — base codes 4
  5. mid-level provider reduction (by NUCC taxonomy) — when ProcedureCode 99203 is absent; ProcedureCode 99204 is absent; ProcedureCode 99213 is absent; ProcedureCode 99214 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
UHC Medicare ASC1 base · 18 adj
United Healthcare Medicare, United Healthcare Medicare Dual
Facility · CPS KY, ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 92% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  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 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
UHC Medicare KY8 base · 18 adj
United Healthcare Medicare, United Healthcare Medicare Dual
Profee · CPS KY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 42% of Medicare lab (KY) — when UHCCPTCategory CLINICAL LABORATORY is present
  3. 60% of Medicare lab (KY) — when UHCCPTCategory CLINICAL LABORATORY is absent
  4. 100% of Medicare drug
  5. 65% of Medicare DME (KY)
  6. 92% of Medicare RVU — when Modifier 95 is present
    • CodeRange 70000–79999 → 70%
  7. 92% of Medicare RVU
    • CodeRange 70000–79999 → 70%
  8. 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) — when Modifier QX is absent; Modifier QZ is absent
  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 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
UHC Medicare TN8 base · 18 adj
United Healthcare Medicare, United Healthcare Medicare Dual
Profee · CPS TN · 2025-04-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare anesthesia
  3. 42% of Medicare lab (KY) — when UHCCPTCategory CLINICAL LABORATORY is present
  4. 60% of Medicare lab (KY) — when UHCCPTCategory CLINICAL LABORATORY is absent
  5. 100% of Medicare drug
  6. 65% of Medicare DME (TN)
  7. 100% of Medicare RVU
    • CodeRange 10000–69999 → 90%
    • CodeRange 70000–79999 → 70%
    • CodeRange 80000–89999 → 60%
    • CodeRange 99200–99499 → 100%
    • CodeRange 90000–99999 → 90%
  8. 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) — when Modifier QX is absent; Modifier QZ is absent
  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 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
Wellcare of KY - Profees4 base · 18 adj
WellCare of KY Medicaid
Profee · CPS KY · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 45% of billed charges — when KYMedicaidBCCode 1 is present
  3. 60% of the Fixed-Fees-Labs fee schedule
  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) — when MidLevelCPTExclusions Exclude is absent
  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 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

Cannot fire (37)

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

Anthem Comm Profee 4% Increase scenario · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 104% of the Carveouts-Modeling fee schedule — when PropertyType-000000007 Clinic is present
  2. 104% of Medicare drug
  3. 104% of the Profee-Fees-Modeling 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Anthem Comm Profee Clinics 15% Increase scenario · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 115% of the Carveouts-Modeling fee schedule — when PropertyType-000000007 Clinic is present
  2. 111% of Medicare drug
  3. 111% of the Profee-Fees-Modeling 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Anthem Comm Profee Clinics 4% Increase scenario · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 104% of the Carveouts-Modeling fee schedule — when PropertyType-000000007 Clinic is present
  2. 104% of Medicare drug
  3. 104% of the Profee-Fees-Modeling 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Anthem Comm Profee Clinics 8% Increase scenario · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 108% of the Carveouts-Modeling fee schedule — when PropertyType-000000007 Clinic is present
  2. 108% of Medicare drug
  3. 108% of the Profee-Fees-Modeling 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Anthem Comm Profee Clinics Flat Rate Increase scenario · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts-Modeling-Flat fee schedule — when PropertyType-000000007 Clinic is present
  2. 100% of Medicare drug
  3. 100% of the Profee-Fees-Modeling 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Anthem Commercial Carve Outs 5% scenario · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts-Modeling-5-Percent fee schedule — when PropertyType-000000007 Clinic is present
  2. 100% of Medicare drug
  3. 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Anthem Commercial Carve Outs Year 2 scenario · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 103.7% of the Carveouts-Modeling-5-Percent fee schedule — when PropertyType-000000007 Clinic is present ⚠︎ named “100% of New Anthem Carveouts” but configured at 103.7%
  2. 100% of Medicare drug
  3. 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Anthem Commercial CarveOuts at 8% scenario · no contract map3 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts-Modeling-Flat-New-Codes fee schedule — when PropertyType-000000007 Clinic is present
  2. 100% of Medicare drug
  3. 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) — when AnthemMDApplicable TRUE is present
  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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem Commercial Option 1 scenario · no contract map3 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare drug
  3. 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) — when AnthemMDApplicable TRUE is present
  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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem IN ASC · contract map selects nothing1 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-12-02 → 2999-12-31
Base terms — first match wins
  1. 110% of Medicare ASC ⚠︎ named “100% Medicare - ASC” but configured at 110%
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2
  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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem Medicare 102% scenario · no contract map4 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 102% of Medicare lab (KY, rates as of 2024-12-10) ⚠︎ named “100% of Medicare Lab” but configured at 102%
  2. 102% of Medicare drug (rates as of 2024-12-10) ⚠︎ named “100% of Medicare Drug” but configured at 102%
  3. 102% of Medicare DME (KY, rates as of 2024-12-10) ⚠︎ named “100% of Medicare DME” but configured at 102%
  4. 102% of Medicare RVU (rates as of 2024-12-10) ⚠︎ named “100% of Medicare RVU” but configured at 102%
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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem Medicare 110% scenario · no contract map4 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 110% of Medicare lab
  2. 110% of Medicare drug
  3. 110% of Medicare DME
  4. 110% 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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Anthem Pathway at Commercial 5% scenario · no contract map3 base · 19 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts-Modeling-5-Percent fee schedule — when PropertyType-000000007 Clinic is present
  2. 100% of Medicare drug
  3. 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. Medicare multiple-therapy reduction (MPPR) — base codes 5; pays 100/50%
  5. mid-level provider reduction (by NUCC taxonomy) — when AnthemMDApplicable TRUE is present; ProcedureCode 80307 is absent; ProcedureCode G0480 is absent; ProcedureCode G0481 is absent; ProcedureCode G0482 is absent; ProcedureCode G0483 is absent
  6. modifier 22 present → 135% of the running amount
  7. modifier 50 present → 150% of the running amount
  8. modifier 52 present → 50% of the running amount
  9. modifier 54 present → 80% 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
Cigna-Backup · no contract map2 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the MD-Profee-Fees fee schedule — when ProviderType MD is present
  2. 100% of the MidLevel-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. 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Humana Medicaid · contract map selects nothing4 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-05-16 → 2999-12-31
Base terms — first match wins
  1. 100% of the Anesthesia-Custom fee schedule
  2. 45% of billed charges — when KYMedicaidBCCode 1 is present
  3. 100% of the Fixed-Fees-Labs fee schedule
  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 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
Humana Medicare scenario · no contract map14 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 104% of the Carveouts fee schedule
  2. 104% of Medicare drug
  3. 54% of the Profee-Fees fee schedule — when CPTCategory Pathology & Laboratory is present
  4. 84% of the Profee-Fees fee schedule — when CPTCategory Radiology is present
  5. 79% of the Profee-Fees fee schedule — when CPTCategory E-Codes is present
  6. 79% of the Profee-Fees fee schedule — when CPTCategory G-Codes is present
  7. 79% of the Profee-Fees fee schedule — when CPTCategory H-Codes is present
  8. 79% of the Profee-Fees fee schedule — when CPTCategory L-Codes is present
  9. 79% of the Profee-Fees fee schedule — when CPTCategory Q-Codes is present
  10. 79% of the Profee-Fees fee schedule — when CPTCategory S-Codes is present
  11. 84% of the Profee-Fees fee schedule — when CPTCategory V-Codes is present
  12. 104% of the Profee-Fees fee schedule — when ProviderType MD is present
  13. 80% of the Profee-Fees fee schedule — when ProviderType MD is absent
  14. 84% 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 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
Humana Medicare 100/85 scenario · no contract map4 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of Medicare lab
  2. 100% of Medicare drug
  3. 100% of Medicare DME
  4. 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 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
Humana Medicare 100/85 scenario · contract map selects nothing15 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-05-16 → 2999-12-31
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 100% of Medicare RVU — when ProviderType MD is present ⚠︎ named “95% Physician Services RVU - MD” but configured at 100%
  13. 100% of Medicare RVU — when ProviderType DO is present ⚠︎ named “95% Physician Services RVU - DO” but configured at 100%
  14. 85% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent ⚠︎ named “76% Extender Services RVU” but configured at 85%
  15. 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. 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. rescale to 98% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana Medicare 100/85 No Change to Lab scenario · no contract map15 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 100% of Medicare RVU — when ProviderType MD is present ⚠︎ named “95% Physician Services RVU - MD” but configured at 100%
  13. 100% of Medicare RVU — when ProviderType DO is present ⚠︎ named “95% Physician Services RVU - DO” but configured at 100%
  14. 85% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent ⚠︎ named “76% Extender Services RVU” but configured at 85%
  15. 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. 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Humana Medicare 100/85 and 80307 at 49.71 scenario · no contract map15 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts-Modeling-Tertiary fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 100% of Medicare RVU — when ProviderType MD is present ⚠︎ named “95% Physician Services RVU - MD” but configured at 100%
  13. 100% of Medicare RVU — when ProviderType DO is present ⚠︎ named “95% Physician Services RVU - DO” but configured at 100%
  14. 85% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent ⚠︎ named “76% Extender Services RVU” but configured at 85%
  15. 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
  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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. rescale to 98% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana Medicare 85 scenario · no contract map15 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 95% of Medicare RVU — when ProviderType MD is present
  13. 95% of Medicare RVU — when ProviderType DO is present
  14. 85% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent ⚠︎ named “76% Extender Services RVU” but configured at 85%
  15. 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. 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Humana Medicare 98/85 and 80307 at 49.71 scenario · no contract map15 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts-Modeling-Tertiary fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 98% of Medicare RVU — when ProviderType MD is present ⚠︎ named “95% Physician Services RVU - MD” but configured at 98%
  13. 98% of Medicare RVU — when ProviderType DO is present ⚠︎ named “95% Physician Services RVU - DO” but configured at 98%
  14. 85% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent ⚠︎ named “76% Extender Services RVU” but configured at 85%
  15. 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
  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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. rescale to 98% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana Medicare Counter 1 scenario · no contract map15 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 100% of Medicare RVU — when ProviderType MD is present ⚠︎ named “95% Physician Services RVU - MD” but configured at 100%
  13. 100% of Medicare RVU — when ProviderType DO is present ⚠︎ named “95% Physician Services RVU - DO” but configured at 100%
  14. 80% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent ⚠︎ named “76% Extender Services RVU” but configured at 80%
  15. 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
  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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. rescale to 98% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana Medicare Counter 2 scenario · no contract map15 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts-Modeling fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 95% of Medicare RVU — when ProviderType MD is present
  13. 95% of Medicare RVU — when ProviderType DO is present
  14. 85% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent ⚠︎ named “76% Extender Services RVU” but configured at 85%
  15. 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
  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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. rescale to 98% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana Medicare Counter 3 scenario · no contract map15 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts-Modeling-Secondary fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 95% of Medicare RVU — when ProviderType MD is present
  13. 95% of Medicare RVU — when ProviderType DO is present
  14. 85% of Medicare RVU — when ProviderType MD is absent; ProviderType DO is absent ⚠︎ named “76% Extender Services RVU” but configured at 85%
  15. 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
  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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. rescale to 98% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Humana Medicare at Anthem Medicare scenario · no contract map0 base · 0 adj
no contract map — cannot be resolved
Humana Mid-Level 80% scenario · no contract map14 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 95% of Medicare RVU — when ProviderType MD is present
  13. 80% of Medicare RVU — when ProviderType MD is absent ⚠︎ named “76% Extender Services RVU” but configured at 80%
  14. 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
  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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Humana Mid-Level 85% scenario · no contract map14 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Carveouts fee schedule
  2. 100% of Medicare drug
  3. 50% of Medicare lab (KY) — when CPTCategory Pathology & Laboratory is present
  4. 80% of Medicare RVU — when CPTCategory Radiology is present
  5. 75% of Medicare RVU — when CPTCategory E-Codes is present
  6. 75% of Medicare RVU — when CPTCategory G-Codes is present
  7. 75% of Medicare RVU — when CPTCategory H-Codes is present
  8. 75% of Medicare RVU — when CPTCategory L-Codes is present
  9. 75% of Medicare RVU — when CPTCategory Q-Codes is present
  10. 75% of Medicare RVU — when CPTCategory S-Codes is present
  11. 80% of Medicare RVU — when CPTCategory V-Codes is present
  12. 95% of Medicare RVU — when ProviderType MD is present
  13. 85% of Medicare RVU — when ProviderType MD is absent ⚠︎ named “76% Extender Services RVU” but configured at 85%
  14. 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
  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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
Humana NC · contract map selects nothing5 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-05-06 → 2999-12-31
Base terms — first match wins
  1. 70% of Medicare anesthesia
  2. 50% of Medicare lab (NC) ⚠︎ named “100% of Medicare Lab” but configured at 50%
  3. 100% of Medicare drug
  4. 70% of Medicare DME (NC) ⚠︎ named “100% of Medicare DME” but configured at 70%
  5. 70% of Medicare RVU ⚠︎ named “100% of Medicare RVU” but configured at 70%
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) — when Modifier QZ is absent; Modifier QX is absent
  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 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
Humana NC Medicare · contract map selects nothing5 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-05-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 50% of Medicare lab (NC) ⚠︎ named “100% of Medicare Lab” but configured at 50%
  3. 100% of Medicare drug
  4. 70% of Medicare DME (NC) ⚠︎ named “100% of Medicare DME” but configured at 70%
  5. 70% of Medicare RVU ⚠︎ named “100% of Medicare RVU” but configured at 70%
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 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
Humana NC Medicare Baseline · contract map selects nothing5 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-05-06 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of Medicare lab (NC)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (NC)
  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) — when Modifier QZ is absent; Modifier QX is absent
  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 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
Humana SC scenario · no contract map14 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 104% of the Carveouts fee schedule
  2. 104% of Medicare drug
  3. 54% of the Profee-Fees fee schedule — when CPTCategory Pathology & Laboratory is present
  4. 84% of the Profee-Fees fee schedule — when CPTCategory Radiology is present
  5. 79% of the Profee-Fees fee schedule — when CPTCategory E-Codes is present
  6. 79% of the Profee-Fees fee schedule — when CPTCategory G-Codes is present
  7. 79% of the Profee-Fees fee schedule — when CPTCategory H-Codes is present
  8. 79% of the Profee-Fees fee schedule — when CPTCategory L-Codes is present
  9. 79% of the Profee-Fees fee schedule — when CPTCategory Q-Codes is present
  10. 79% of the Profee-Fees fee schedule — when CPTCategory S-Codes is present
  11. 84% of the Profee-Fees fee schedule — when CPTCategory V-Codes is present
  12. 104% of the Profee-Fees fee schedule — when ProviderType MD is present
  13. 80% of the Profee-Fees fee schedule — when ProviderType MD is absent
  14. 84% 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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare 1.07 scenario · no contract map4 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 101.7% of Medicare lab (rates as of 2024-12-23) ⚠︎ named “100% of Medicare Lab” but configured at 101.7%
  2. 101.7% of Medicare drug (rates as of 2024-12-23) ⚠︎ named “100% of Medicare Drug” but configured at 101.7%
  3. 101.7% of Medicare DME ⚠︎ named “100% of Medicare DME” but configured at 101.7%
  4. 101.7% of Medicare RVU (rates as of 2024-12-23) ⚠︎ named “100% of Medicare RVU” but configured at 101.7%
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 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare 1.09% scenario · no contract map4 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 101.9% of Medicare lab (rates as of 2024-12-23) ⚠︎ named “100% of Medicare Lab” but configured at 101.9%
  2. 101.9% of Medicare drug ⚠︎ named “100% of Medicare Drug” but configured at 101.9%
  3. 101.9% of Medicare DME ⚠︎ named “100% of Medicare DME” but configured at 101.9%
  4. 101.9% of Medicare RVU (rates as of 2024-12-23) ⚠︎ named “100% of Medicare RVU” but configured at 101.9%
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 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
UHC Medicare Lab Model · contract map selects nothing7 base · 17 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-05-12 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 60% of Medicare lab (KY, rates as of 2025-05-12) — when UHCCPTCategory CLINICAL LABORATORY is present ⚠︎ named “42% of Medicare Lab for Clinical” but configured at 60%
  3. 60% of Medicare lab (KY) — when UHCCPTCategory CLINICAL LABORATORY is absent
  4. 100% of Medicare drug
  5. 65% of Medicare DME (KY)
  6. 92% 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 — 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
UHC Medicare Model 2 · contract map selects nothing7 base · 17 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-05-12 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 42% of Medicare lab (KY) — when UHCCPTCategory CLINICAL LABORATORY is present
  3. 60% of Medicare lab (KY) — when UHCCPTCategory CLINICAL LABORATORY is absent
  4. 100% of Medicare drug
  5. 65% of Medicare DME (KY)
  6. 100% of Medicare RVU (rates as of 2025-05-12) ⚠︎ named “92% of Medicare RVU KY” but configured at 100%
  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 — 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges
UHC Medicare Model 3 · contract map selects nothing7 base · 17 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2025-05-12 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 60% of Medicare lab (KY, rates as of 2025-05-12) — when UHCCPTCategory CLINICAL LABORATORY is present ⚠︎ named “42% of Medicare Lab for Clinical” but configured at 60%
  3. 60% of Medicare lab (KY) — when UHCCPTCategory CLINICAL LABORATORY is absent
  4. 100% of Medicare drug
  5. 65% of Medicare DME (KY)
  6. 100% of Medicare RVU (rates as of 2025-05-12) ⚠︎ named “92% of Medicare RVU KY” but configured at 100%
  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 — 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 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. cap each charge and the account total at 100% of billed charges