Customer detail

RIA

105
live contracts
3
cannot fire
21
calc types
2
SQL bodies
1
of those blocked
7
map conflicts

Methodology mix

ModifierAdjustment1,345
PercentOfFees230
MedicareRVU126
LesserOfAdjustment104
MedicareMultipleProcedureAdjustment103
MedicareMultipleEndoscopyAdjustment103
MedicareMultipleRadiologyAdjustment96
MedicareDrug73
MedicareDME70
MedicareLab68
FlatPercentOfCharges40
CalculationBuilder15
BilateralSurgeryV2Adjustment15
MedicareOPPSCapAdjustment10
MultipleRadiologyAdjustment7
MedicareBilateralSurgeryAdjustment6
MedicareAnesthesia5
FlatFee4
PercentOfCharges3
ChargeLevelSqlAdjustment1
SqlExpression1

Contracts

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

70% Medicare6 base · 18 adj
WellCare Medicare
Profee · ECFOI · 2010-05-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 70% of Medicare lab
  3. 70% of Medicare drug
  4. 70% of Medicare DME
  5. 70% of Medicare RVU
  6. 70% of the Fixed-Fees-Contractor-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — 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. Medicare OPPS cap
  18. cap each charge and the account total at 100% of billed charges
85% Medicare6 base · 18 adj
Employee Benefit Management Services
Profee · ECFOI · 2020-10-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 85% of Medicare lab
  3. 85% of Medicare drug
  4. 85% of Medicare DME
  5. 85% of Medicare RVU
  6. 70% of the Curative - MRI/MRA/CT Scan/PET 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. Medicare OPPS cap
  18. cap each charge and the account total at 100% of billed charges
90% Medicare 6 base · 17 adj
CarePlus
Profee · ECFOI · 2025-12-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 90% of Medicare lab
  3. 90% of Medicare drug
  4. 90% of Medicare DME
  5. 90% of Medicare RVU
  6. 90% of the Curative - MRI/MRA/CT Scan/PET 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
95% Medicare6 base · 18 adj
Freedom Health
Profee · 3 named facilities · 2024-01-01 → 2999-12-31
Optimum Healthcare
Profee · 3 named facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 95% of Medicare DME
  3. 95% of Medicare drug
  4. 95% of Medicare lab
  5. 95% of Medicare RVU
  6. 100% of the Curative - MRI/MRA/CT Scan/PET 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. Medicare OPPS cap
  18. cap each charge and the account total at 100% of billed charges
AARP-ECFOI5 base · 18 adj
AARP
Profee · ECFOI · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare DME (rates as of 2012-04-01)
  3. 100% of Medicare drug (rates as of 2012-04-01)
  4. 100% of Medicare lab (rates as of 2012-04-01)
  5. 100% of Medicare RVU (rates as of 2012-04-01)
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
AARP-IMI7 base · 19 adj
AARP
Profee · IMI · 2025-09-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 105% of Medicare DME (rates as of 2020-04-01)
  4. 105% of Medicare drug (rates as of 2020-04-01)
  5. 105% of Medicare lab (rates as of 2020-04-01)
  6. 105% of Medicare RVU (rates as of 2020-04-01)
  7. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  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. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
AARP-MICTIC-20258 base · 18 adj
AARP
Profee · MICTIC · 2025-12-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 100% of Medicare anesthesia (rates as of 2020-01-01)
  4. 40% of Medicare DME (rates as of 2020-01-01)
  5. 100% of Medicare drug
  6. 60% of Medicare lab (rates as of 2020-01-01)
  7. 161.6% of Medicare RVU (rates as of 2020-01-01)
  8. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Aetna-ECFOI10 base · 19 adj
Aetna, Aetna Medicare
Profee · ECFOI · 2023-01-01 → 2025-09-14
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. computed expression (operands follow)
  4. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  5. Multiply 1% of the Fixed-Fees-Percentage fee schedule
  6. 100% of Medicare DME (rates as of 2008-04-01)
  7. 100% of Medicare drug (rates as of 2008-04-01)
  8. 100% of Medicare lab (rates as of 2008-04-01)
  9. 100% of Medicare RVU (rates as of 2008-04-01)
  10. 100% of the Curative - MRI/MRA/CT Scan/PET 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. bilateral-surgery adjustment (v2) — base codes 1; pays 100/50%
  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. Medicare OPPS cap
  19. cap each charge and the account total at 80% of billed charges
Aetna-ECFOI-202510 base · 19 adj
Aetna
Profee · ECFOI · 2025-09-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. computed expression (operands follow)
  3. 100% of Medicare RVU
  4. Multiply 100% of the Curative - Drugs, biologicals, and tracers fee schedule
  5. 100% of the Fixed-Fees-Secondary fee schedule
  6. 130% of Medicare DME (rates as of 2024-01-01)
  7. 130% of Medicare drug (rates as of 2024-01-01)
  8. 130% of Medicare lab (rates as of 2024-01-01)
  9. 100% of Medicare RVU (rates as of 2024-01-01)
    • CodeRange 20100–29916 → 130%
    • CodeRange 99202–99498 → 140%
    • CodeRange 10000–99999 → 130%
    • CodeRange A0000–Z9999 → 130%
  10. 100% of the Curative - MRI/MRA/CT Scan/PET 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. bilateral-surgery adjustment (v2) — base codes 1; pays 100/50%
  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. Medicare OPPS cap
  19. cap each charge and the account total at 80% of billed charges
Aetna-IMI3 base · 18 adj
Aetna
Profee · IMI · 2023-01-01 → 2024-03-14
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 0% of the Excluded-ProcCodes fee schedule
  3. 100% of the Curative - MRI/MRA/CT Scan/PET 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. bilateral-surgery adjustment (v2) — base codes 1; pays 100/50%
  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 80% of billed charges
Aetna-IMI4 base · 18 adj
Aetna
Profee · IMI · 2024-03-15 → 2025-03-14
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 0% of the Excluded-ProcCodes fee schedule
  3. 105% of Medicare RVU (rates as of 2023-01-01)
  4. 100% of the Curative - MRI/MRA/CT Scan/PET 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. bilateral-surgery adjustment (v2) — base codes 1; pays 100/50%
  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 80% of billed charges
Aetna-IMI4 base · 18 adj
Aetna
Profee · IMI · 2025-03-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 0% of the Excluded-ProcCodes fee schedule
  3. 110% of Medicare RVU (rates as of 2023-01-01)
  4. 100% of the Curative - MRI/MRA/CT Scan/PET 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. bilateral-surgery adjustment (v2) — base codes 1; pays 100/50%
  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 80% of billed charges
Aetna-MICTIC16 base · 18 adj
Aetna
Profee · MICTIC · 2015-01-01 → 2024-01-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 0% of the Excluded-ProcCodes fee schedule
  3. 100% of the Fixed-Fees-Carveout fee schedule
  4. computed expression (operands follow)
  5. 130% of Medicare RVU (rates as of 2014-01-01)
  6. Multiply 100% of the Fixed-Fees-Diagnostic-Rad fee schedule
  7. computed expression (operands follow)
  8. 125% of Medicare RVU (rates as of 2014-01-01)
  9. Multiply 100% of the Fixed-Fees-Digital-Mammography fee schedule
  10. computed expression (operands follow)
  11. 115% of Medicare RVU (rates as of 2014-01-01)
  12. Multiply 100% of the Fixed-Fees-Add-Surg-Diagn fee schedule
  13. computed expression (operands follow)
  14. 120% of the Fixed-Fees-Percentage fee schedule
  15. Multiply 100% of Medicare RVU (rates as of 2021-01-01)
  16. 120% of the Curative - MRI/MRA/CT Scan/PET 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. bilateral-surgery adjustment (v2) — base codes 1; pays 100/50%
  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-MICTIC6 base · 19 adj
Aetna
Profee · MICTIC · 2024-02-01 → 2999-12-31
Base terms — first match wins
  1. computed expression (operands follow)
  2. 100% of the Fixed-Fees-Percentage fee schedule
  3. Multiply 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  4. 135% of Medicare RVU (rates as of 2023-01-01) — when CodeRange in 74261–74261
  5. 135% of Medicare RVU (rates as of 2023-01-01)
  6. 100% of the Curative - MRI/MRA/CT Scan/PET 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. bilateral-surgery adjustment (v2) — base codes 1; pays 100/50%
  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. Medicare OPPS cap
  19. cap each charge and the account total at 100% of billed charges
Aetna-Medicare-EFCOI6 base · 17 adj
Aetna Medicare
Profee · ECFOI · 2025-09-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare drug
  3. 100% of Medicare lab
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of the Curative - MRI/MRA/CT Scan/PET 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 80% of billed charges
Aetna-Medicare-IMI4 base · 17 adj
Aetna Medicare
Profee · IMI · 2024-03-15 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 0% of the Excluded-ProcCodes fee schedule
  3. 100% of Medicare RVU
  4. 100% of the Curative - MRI/MRA/CT Scan/PET 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. 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 80% of billed charges
Aetna-Medicare-MICTIC4 base · 17 adj
Aetna Medicare
Profee · MICTIC · 2015-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 0% of the Excluded-ProcCodes fee schedule
  3. 100% of Medicare RVU
  4. 120% of the Curative - MRI/MRA/CT Scan/PET 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. 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
Aetna-Medicare-MICTIC4 base · 17 adj
Aetna Medicare
Profee · MICTIC · 2024-02-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 0% of the Excluded-ProcCodes fee schedule
  3. 100% of Medicare RVU
  4. 100% of the Curative - MRI/MRA/CT Scan/PET 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. 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
Aetna-Medicare-MICTIC4 base · 18 adj
Aetna Medicare
Profee · MICTIC · 2024-02-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 0% of the Excluded-ProcCodes fee schedule
  3. 100% of Medicare RVU
  4. 100% of the Curative - MRI/MRA/CT Scan/PET 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. custom SQL — Hardcoded flat dollar override of $4,920 for HCPCS A9596 (a radiopharmaceutical), applied as a charge-level adjustment.
  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-Medicare-RAOC-RIA3 base · 17 adj
Aetna Medicare
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2015-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare RVU
  3. 100% of the Curative - MRI/MRA/CT Scan/PET 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. 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 80% of billed charges
Aetna-RAOC-RIA6 base · 18 adj
Aetna
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2015-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 150% of Medicare DME (rates as of 2014-01-01)
  3. 150% of Medicare drug (rates as of 2014-01-01)
  4. 150% of Medicare lab (rates as of 2014-01-01)
  5. 150% of Medicare RVU (rates as of 2014-01-01)
  6. 100% of the Curative - MRI/MRA/CT Scan/PET 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. Medicare OPPS cap
  18. cap each charge and the account total at 80% of billed charges
Avmed-Medicare-MICTIC6 base · 17 adj
Avmed Medicare
Profee · MICTIC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 147% of Medicare DME
  3. 147% of Medicare drug
  4. 147% of Medicare lab
  5. 147% of Medicare RVU
  6. 100% of the Fixed-Fees-Contractor-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — 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
BCBS-ECFOI5 base · 18 adj
BCBS, BCBS Medicare
Profee · ECFOI · 2023-06-27 → 2024-04-30
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare drug ⚠︎ named “106% of Medicare ASP Drug Rates” but configured at 100%
  3. computed expression (operands follow)
  4. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
  5. Multiply 1% of the Fixed-Fees-Percentage 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. bilateral-surgery adjustment (v2) — base codes 1; pays 75/75%
  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
BCBS-ECFOI-20245 base · 18 adj
BCBS, BCBS Medicare
Profee · ECFOI · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare drug ⚠︎ named “106% of Medicare ASP Drug Rates” but configured at 100%
  3. computed expression (operands follow)
  4. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
  5. Multiply 1% of the Fixed-Fees-Percentage fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. bilateral-surgery adjustment (v2) — base codes 1; pays 75/75%
  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
BCBS-IMI5 base · 18 adj
BCBS
Profee · IMI · 2023-06-27 → 2024-04-30
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare drug ⚠︎ named “106% of Medicare ASP Drug Rates” but configured at 100%
  3. computed expression (operands follow)
  4. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
  5. Multiply 1% of the Fixed-Fees-Percentage 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. bilateral-surgery adjustment (v2) — base codes 1; pays 75/75%
  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
BCBS-IMI-20245 base · 18 adj
BCBS
Profee · IMI · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare drug ⚠︎ named “106% of Medicare ASP Drug Rates” but configured at 100%
  3. computed expression (operands follow)
  4. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
  5. Multiply 1% of the Fixed-Fees-Percentage fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. bilateral-surgery adjustment (v2) — base codes 1; pays 75/75%
  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
BCBS-MICTIC8 base · 18 adj
BCBS
Profee · MICTIC · 2023-06-27 → 2024-04-30
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Digital-Mammography fee schedule
  3. 139% of Medicare DME (rates as of 2007-01-01)
  4. 139% of Medicare drug (rates as of 2007-01-01)
  5. 139% of Medicare lab (rates as of 2007-01-01)
  6. 139% of the Fixed-Fees-Carveout fee schedule
  7. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
  8. 55% 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. 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
BCBS-MICTIC-20248 base · 17 adj
BCBS
Profee · MICTIC · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Digital-Mammography fee schedule
  3. 139% of Medicare DME (rates as of 2007-01-01)
  4. 139% of Medicare drug (rates as of 2007-01-01)
  5. 139% of Medicare lab (rates as of 2007-01-01)
  6. 139% of Medicare RVU (rates as of 2007-01-01)
  7. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
  8. 55% 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. multiple-radiology reduction (contract rules) — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. modifier 22 present → 135% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. 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
BCBS-Medicare-IMI4 base · 17 adj
BCBS Medicare
Profee · IMI · 2017-02-01 → 2024-04-30
Base terms — first match wins
  1. 60% of Medicare DME
  2. 100% of Medicare drug
  3. 60% of Medicare lab
  4. 70% 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
BCBS-Medicare-IMI-20244 base · 17 adj
BCBS Medicare
Profee · IMI · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 60% of Medicare DME
  2. 100% of Medicare drug
  3. 60% of Medicare lab
  4. 70% 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. multiple-radiology reduction (contract rules) — 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
BCBS-Medicare-MICTIC6 base · 17 adj
BCBS Medicare
Profee · MICTIC · 2024-01-01 → 2024-04-30
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare DME
  3. 100% of Medicare drug
  4. 100% of Medicare lab
  5. 100% of Medicare RVU
  6. 100% of the Fixed-Fees-Contractor-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — 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
BCBS-Medicare-MICTIC-20246 base · 17 adj
BCBS Medicare
Profee · MICTIC · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare DME
  3. 100% of Medicare drug
  4. 100% of Medicare lab
  5. 100% of Medicare RVU
  6. 100% of the Fixed-Fees-Contractor-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. multiple-radiology reduction (contract rules) — 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
BCBS-Medicare-RAOC-RIA5 base · 17 adj
BCBS Medicare
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2010-01-01 → 2024-04-30
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare DME
  3. 100% of Medicare drug
  4. 100% of Medicare lab
  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. 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
BCBS-Medicare-RAOC-RIA-20245 base · 17 adj
BCBS Medicare
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare DME
  3. 100% of Medicare drug
  4. 100% of Medicare lab
  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. multiple-radiology reduction (contract rules) — 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
BCBS-RAOC-RIA6 base · 18 adj
BCBS
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2023-06-27 → 2024-04-30
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 126% of Medicare DME (FL)
  3. 126% of Medicare drug
  4. 126% of Medicare lab
  5. 126% of Medicare RVU
  6. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals 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. bilateral-surgery adjustment (v2) — base codes 1; pays 75/75%
  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
BCBS-RAOC-RIA-20246 base · 18 adj
BCBS
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 126% of Medicare DME (FL)
  3. 126% of Medicare drug
  4. 126% of Medicare lab
  5. 126% of Medicare RVU
  6. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. multiple-radiology reduction (contract rules) — base codes 4
  4. bilateral-surgery adjustment (v2) — base codes 1; pays 75/75%
  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
Beech-Street-RAOC-RIA1 base · 0 adj
Beech Street
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2006-11-01 → 2999-12-31
Base terms — first match wins
  1. 80% of billed charges
CarePlus-ECFOI3 base · 17 adj
CarePlus
Profee · ECFOI · 2023-01-01 → 2025-11-30
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 90% of the Fixed-Fees-Contractor-Rates fee schedule
  3. 90% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals 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
CarePlus-RAOC-RIA5 base · 17 adj
CarePlus
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 85% of Medicare DME
  3. 85% of Medicare drug
  4. 85% of Medicare lab
  5. 85% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. 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
Carisk-ECFOI6 base · 17 adj
Carisk
Profee · ECFOI · 2024-05-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Carveout fee schedule
  2. computed expression (operands follow)
  3. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  4. Multiply 80% of the Fixed-Fees-Diagnostic-Rad fee schedule
  5. 120% of billed charges — when IsRadioIsotopesCode Yes is present
  6. 100% of the Curative - MRI/MRA/CT Scan/PET 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. 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
Charges1 base · 0 adj
Charges
Profee · all facilities · 1900-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the ChargeMaster-Fixed-Fees fee schedule
Cigna-ECFOI-20247 base · 17 adj
Cigna
Profee · ECFOI · 2024-03-01 → 2025-02-28
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 130% of Medicare DME (rates as of 2022-01-01)
  4. 130% of Medicare drug (rates as of 2022-01-01)
  5. 130% of Medicare lab (rates as of 2022-01-01)
  6. 130% of Medicare RVU (rates as of 2022-01-01)
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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-ECFOI-20257 base · 17 adj
Cigna
Profee · ECFOI · 2025-03-01 → 2026-02-28
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 133% of Medicare DME (rates as of 2022-01-01)
  4. 133% of Medicare drug (rates as of 2022-01-01)
  5. 133% of Medicare lab (rates as of 2022-01-01)
  6. 133% of Medicare RVU (rates as of 2022-01-01)
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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-ECFOI-20267 base · 17 adj
Cigna
Profee · ECFOI · 2026-03-01 → 2099-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 136% of Medicare DME (rates as of 2022-01-01)
  4. 136% of Medicare drug (rates as of 2022-01-01)
  5. 136% of Medicare lab (rates as of 2022-01-01)
  6. 136% of Medicare RVU (rates as of 2022-01-01)
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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-IMI7 base · 17 adj
Cigna
Profee · IMI · 2023-12-15 → 2024-12-14
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 130% of Medicare DME (rates as of 2022-01-01)
  4. 130% of Medicare drug (rates as of 2022-01-01)
  5. 130% of Medicare lab (rates as of 2022-01-01)
  6. 130% of Medicare RVU (rates as of 2022-01-01)
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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-IMI7 base · 17 adj
Cigna
Profee · IMI · 2024-12-15 → 2025-12-14
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 133% of Medicare DME (rates as of 2022-01-01)
  4. 133% of Medicare drug (rates as of 2022-01-01)
  5. 133% of Medicare lab (rates as of 2022-01-01)
  6. 133% of Medicare RVU (rates as of 2022-01-01)
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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-IMI7 base · 17 adj
Cigna
Profee · IMI · 2025-12-15 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 136% of Medicare DME (rates as of 2022-01-01)
  4. 136% of Medicare drug (rates as of 2022-01-01)
  5. 136% of Medicare lab (rates as of 2022-01-01)
  6. 136% of Medicare RVU (rates as of 2022-01-01)
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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-MICTIC7 base · 17 adj
Cigna
Profee · MICTIC · 2015-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 100% of Medicare DME (rates as of 2013-01-01)
  4. 100% of Medicare drug (rates as of 2013-01-01)
  5. 100% of Medicare lab (rates as of 2013-01-01)
  6. 100% of Medicare RVU (rates as of 2013-01-01)
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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-Medicare-ECFOI-2024 7 base · 17 adj
Cigna Medicare
Profee · ECFOI · 2024-03-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. flat $1150 — when CodeRange in 78811–78816
  3. 100% of Medicare DME (rates as of 2022-01-01)
  4. 100% of Medicare drug (rates as of 2022-01-01)
  5. 100% of Medicare lab (rates as of 2022-01-01)
  6. 100% of Medicare RVU (rates as of 2022-01-01)
  7. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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-RAOC-RIA3 base · 17 adj
Cigna
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2010-08-15 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 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
  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
Curative - ECFOI5 base · 17 adj
Curative
Profee · ECFOI · 2025-09-14 → 2999-12-31
Base terms — first match wins
  1. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  2. percent-of-charges, rate read from the Curative - Drugs, biologicals, and tracers schedule
  3. 115% of Medicare RVU — when CodeRange in 70000–79999 ⚠︎ named “100% of Medicare RVU” but configured at 115%
    • CodeRange 77065–77067 → 120%
    • CodeRange 77641–77641 → 120%
    • CodeRange 76536–76536 → 120%
    • CodeRange 76700–76700 → 120%
    • CodeRange 76705–76705 → 120%
    • CodeRange 76775–76776 → 120%
    • CodeRange 76830–76830 → 120%
    • CodeRange 76856–76857 → 120%
    • CodeRange 77080–77080 → 100%
  4. 100% of Medicare RVU
  5. 30% 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
Curative - IMI5 base · 17 adj
Curative
Profee · IMI · 2025-09-14 → 2999-12-31
Base terms — first match wins
  1. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  2. percent-of-charges, rate read from the Curative - Drugs, biologicals, and tracers schedule
  3. 115% of Medicare RVU — when CodeRange in 70000–79999 ⚠︎ named “100% of Medicare RVU” but configured at 115%
    • CodeRange 77065–77067 → 120%
    • CodeRange 77641–77641 → 120%
    • CodeRange 76536–76536 → 120%
    • CodeRange 76700–76700 → 120%
    • CodeRange 76705–76705 → 120%
    • CodeRange 76775–76776 → 120%
    • CodeRange 76830–76830 → 120%
    • CodeRange 76856–76857 → 120%
    • CodeRange 77080–77080 → 100%
  4. 100% of Medicare RVU
  5. 30% 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
Curative - MICTIC5 base · 17 adj
Curative
Profee · MICTIC · 2025-09-14 → 2999-12-31
Base terms — first match wins
  1. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  2. percent-of-charges, rate read from the Curative - Drugs, biologicals, and tracers schedule
  3. 115% of Medicare RVU — when CodeRange in 70000–79999 ⚠︎ named “100% of Medicare RVU” but configured at 115%
    • CodeRange 77065–77067 → 120%
    • CodeRange 77641–77641 → 120%
    • CodeRange 76536–76536 → 120%
    • CodeRange 76700–76700 → 120%
    • CodeRange 76705–76705 → 120%
    • CodeRange 76775–76776 → 120%
    • CodeRange 76830–76830 → 120%
    • CodeRange 76856–76857 → 120%
    • CodeRange 77080–77080 → 100%
  4. 100% of Medicare RVU
  5. 30% 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
Devoted-Health-RAOC-RIA6 base · 17 adj
Devoted Health
Profee · ECFOI, IMI, MICTIC, RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2022-12-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 30% 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
EFCOI-Emblem Health-Profees2 base · 17 adj
Emblem Health
Profee · ECFOI · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  2. 100% of Medicare RVU (rates as of 2023-01-01)
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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
Employee-Benefit-Management-Services-RAOC-RIA5 base · 17 adj
Employee Benefit Management Services
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2020-10-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 85% of Medicare DME
  3. 85% of Medicare drug
  4. 85% of Medicare lab
  5. 85% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. 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
Evolutions-RAOC-RIA6 base · 17 adj
Evolutions Healthcare Systems
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2023-10-16 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 125% of Medicare DME
  3. 125% of Medicare drug
  4. 125% of Medicare lab
  5. 125% of Medicare RVU
  6. 100% of billed charges — when IsRadioIsotopesCode Yes is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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
FL-Medicaid2 base · 1 adj
FL-Medicaid
Profee · all facilities · 2024-01-01 → 2999-12-31
WellCare Medicaid
Profee · ECFOI · 2010-05-01 → 2999-12-31
Sunshine
Profee · ECFOI, IMI, MICTIC · 2023-08-20 → 2999-12-31
Ambetter
Profee · ECFOI · 2023-08-21 → 2999-12-31
United Healthcare Medicaid
Profee · ECFOI, IMI, MICTIC · 2025-07-01 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Florida Medicaid carve-out fee with an added NPI-to-specialty-code resolution layer (via a CommonData function) that falls back to a generic '011' specialty or drops the specialty filter entirely when the code-specific specialty match fails.
  2. 100% of billed charges
Adjustments — all apply, in order
  1. cap each charge and the account total at 100% of billed charges
Florida-Health-ECFOI18 base · 17 adj
Florida Health
Profee · ECFOI · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 100% of Medicare RVU — when ProcedureCodes 77080 is present
  4. 110% of Medicare RVU — when CodeRange in 10140–10160
  5. 110% of Medicare RVU — when CodeRange in 11042–11045
  6. 110% of Medicare RVU — when CodeRange in 29580–29580
  7. 110% of Medicare RVU — when CodeRange in 36465–36483
  8. 110% of Medicare RVU — when CodeRange in 37765–37766
  9. 110% of Medicare RVU — when CodeRange in 76942–76942
  10. 110% of Medicare RVU — when CodeRange in 93970–93971
  11. 110% of Medicare RVU — when CodeRange in 99024–99024
  12. 146% of Medicare lab
  13. 146% of Medicare drug
  14. 146% of Medicare DME
  15. 146% of Medicare RVU
  16. 100% of the Fixed-Fees-Contractor-Rates fee schedule
  17. 100% of the MAC-RadioPharm-Fixed-Fees fee schedule
  18. 100% of the MAC-Invoice-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. 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
Florida-Health-Medicare-ECFOI16 base · 17 adj
Florida Health Medicare
Profee · ECFOI · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 100% of Medicare RVU — when ProcedureCodes 77080 is present
  4. 100% of Medicare RVU — when CodeRange in 10140–10160
  5. 100% of Medicare RVU — when CodeRange in 11042–11045
  6. 100% of Medicare RVU — when CodeRange in 29580–29580
  7. 100% of Medicare RVU — when CodeRange in 36465–36483
  8. 100% of Medicare RVU — when CodeRange in 37765–37766
  9. 100% of Medicare RVU — when CodeRange in 76942–76942
  10. 100% of Medicare RVU — when CodeRange in 93970–93971
  11. 100% of Medicare RVU — when CodeRange in 99024–99024
  12. 110% of Medicare lab
  13. 110% of Medicare drug
  14. 110% of Medicare DME
  15. 110% of Medicare RVU
  16. 100% of the Fixed-Fees-Contractor-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — 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
Florida-Health-RAOC-RIA5 base · 17 adj
Florida Health, Florida Health Medicare
Profee · RAOC / RIA - Daytona · 2006-04-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 110% of Medicare lab
  3. 110% of Medicare drug
  4. 110% of Medicare DME
  5. 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. 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
HPI-ECFOI5 base · 17 adj
HPI
Profee · ECFOI · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 120% of Medicare DME
  3. 120% of Medicare drug
  4. 120% of Medicare lab
  5. 120% 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
HPI-ECFOI5 base · 17 adj
HPI
Profee · ECFOI · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 120% of Medicare DME
  3. 120% of Medicare drug
  4. 120% of Medicare lab
  5. 120% 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
Health-First-RAOC-RIA-Ocala5 base · 17 adj
Health First
Profee · RAOC / RIA - Ocala · 2018-08-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 115% of Medicare lab
  3. 115% of Medicare drug
  4. 115% of Medicare DME
  5. 115% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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-ECFOI3 base · 17 adj
Humana, Humana Medicare
Profee · ECFOI · 2023-01-01 → 2025-11-30
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Humana-Fixed-Fees fee schedule
  3. 90% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals 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-ECFOI-20257 base · 17 adj
Humana, Humana Medicare
Profee · ECFOI · 2025-12-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 105% of Medicare RVU
  6. 100% of the Humana-Fixed-Fees fee schedule
  7. 100% of the Curative - MRI/MRA/CT Scan/PET 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-IMI2 base · 17 adj
Humana, Humana Medicare
Profee · 3 named facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 65% of the Curative - MRI/MRA/CT Scan/PET 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-Medicare-RAOC-RIA2 base · 17 adj
Humana Medicare
Profee · RAOC / RIA - Daytona · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 90% of the Curative - MRI/MRA/CT Scan/PET 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. 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-RAOC-RIA2 base · 17 adj
Humana
Profee · RAOC / RIA - Daytona · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 110% of the Curative - MRI/MRA/CT Scan/PET 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. 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
Medicare8 base · 18 adj
Medicare
Profee · all facilities · 2024-01-01 → 2999-12-31
CarePlus
Profee · MICTIC · 2024-01-01 → 2999-12-31
Cornerstone Hospice and Palliative Care
Profee · RAOC / RIA - Ocala · 2014-06-02 → 2999-12-31
Health First Medicare
Profee · RAOC / RIA - Ocala · 2018-08-01 → 2999-12-31
Hospice of Marion County
Profee · RAOC / RIA - Ocala · 2003-10-14 → 2999-12-31
Ilumed
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2022-01-01 → 2999-12-31
WellCare
Profee · ECFOI, MICTIC · 2024-01-01 → 2999-12-31
VA Community Care Network
Profee · ECFOI · 2024-01-01 → 2999-12-31
Sunshine Medicare
Profee · ECFOI · 2019-07-01 → 2999-12-31
Optimum Healthcare
Profee · ECFOI, MICTIC · 2024-01-01 → 2999-12-31
Freedom Health
Profee · ECFOI, MICTIC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of the Fixed-Fees-Contractor-Rates fee schedule
  7. 100% of the MAC-RadioPharm-Fixed-Fees fee schedule
  8. 100% of the MAC-Invoice-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. 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. Medicare OPPS cap
  18. cap each charge and the account total at 100% of billed charges
MultiPlan-RAOC-RIA1 base · 0 adj
MultiPlan
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2011-12-31 → 2999-12-31
Base terms — first match wins
  1. 80% of billed charges
Oscar-RAOC-RIA5 base · 17 adj
Oscar
Profee · MICTIC, RAOC / RIA - Ocala · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 115% of Medicare DME
  3. 115% of Medicare drug
  4. 115% of Medicare lab
  5. 115% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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
Prime-Health-MICTIC2 base · 17 adj
Prime Health
Profee · MICTIC · 2010-08-16 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 85% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. 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
Prime-Health-RAOC-RIA1 base · 0 adj
Prime Health
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2006-11-21 → 2999-12-31
Base terms — first match wins
  1. 90% of billed charges
Prime-Health-Workers-Comp-MICTIC1 base · 17 adj
Prime Health Workers Comp
Profee · MICTIC · 2023-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Curative - MRI/MRA/CT Scan/PET 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. 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
Prime-Health-Workers-Comp-RAOC-RIA1 base · 17 adj
Prime Health Workers Comp
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2023-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Curative - MRI/MRA/CT Scan/PET 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. 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
Self-Pay8 base · 17 adj
Self Pay
Profee · MICTIC, MSN, RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala, STR · 1900-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $52.65 — when CodeRange in 77062–77062
  2. 100% of Medicare RVU — when ProcedureCodes 77067 is present
  3. 100% of Medicare RVU (rates as of 2022-01-01) — when ProcedureCodes 77063 is present
  4. 200% of Medicare lab (rates as of 2022-01-01)
  5. 200% of Medicare drug (rates as of 2022-01-01)
  6. 200% of Medicare DME (rates as of 2022-01-01)
  7. 200% of Medicare RVU (rates as of 2022-01-01)
  8. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule — when ProcedureCodes Q9982 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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
Self-Pay-ECFOI8 base · 17 adj
Self Pay
Profee · 16 named facilities · 1900-01-01 → 2025-12-31
Base terms — first match wins
  1. flat $52.65 — when CodeRange in 77062–77062
  2. 100% of Medicare RVU — when ProcedureCodes 77067 is present
  3. 100% of Medicare RVU (rates as of 2022-01-01) — when ProcedureCodes 77063 is present
  4. 200% of Medicare lab (rates as of 2022-01-01)
  5. 200% of Medicare drug (rates as of 2022-01-01)
  6. 200% of Medicare DME (rates as of 2022-01-01)
  7. 200% of Medicare RVU (rates as of 2022-01-01)
  8. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule — when ProcedureCodes Q9982 is present
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. 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
Self-Pay-ECFOI-20262 base · 17 adj
Self Pay
Profee · 16 named facilities · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  2. flat $0
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
Self-Pay-OPI-20261 base · 17 adj
Self Pay
Profee · 1 named facilities · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Curative - MRI/MRA/CT Scan/PET 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
SimPlan-ECFOI-RIA7 base · 18 adj
SimPlan
Profee · ECFOI · 2021-04-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 110% of Medicare DME
  4. 110% of Medicare drug
  5. 110% of Medicare lab
  6. 110% of Medicare RVU
  7. 30% 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. bilateral-surgery adjustment (v2) — base codes 1; pays 75/75%
  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
SimPlan-RAOC-RIA7 base · 18 adj
SimPlan
Profee · ECFOI · 2021-04-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 110% of Medicare DME
  4. 110% of Medicare drug
  5. 110% of Medicare lab
  6. 110% of Medicare RVU
  7. 30% 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. bilateral-surgery adjustment (v2) — base codes 1; pays 75/75%
  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
Tricare-EFCOI6 base · 17 adj
Tricare
Profee · ECFOI · 2004-05-03 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 85% of the Fixed-Fees-Carveout fee schedule
  3. 85% of the Fixed-Fees-Secondary fee schedule
  4. 85% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  5. 100% of the Fixed-Fees-Contractor-Rates fee schedule
  6. 85% 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
Tricare-IMI7 base · 17 adj
Tricare
Profee · IMI · 2004-05-03 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Carveout-Fees fee schedule
  3. 100% of the Fixed-Fees-Carveout fee schedule
  4. 80% of the Fixed-Fees-Secondary fee schedule — when CodeRange in 80000–89999
  5. 100% of the Fixed-Fees-Secondary fee schedule
  6. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  7. 60% 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
Tricare-RAOC-RIA5 base · 17 adj
Tricare
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2017-03-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 85% of the Fixed-Fees-Carveout fee schedule
  3. 85% of the Fixed-Fees-Secondary fee schedule
  4. 85% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  5. 85% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. 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
Trustmark-Health-Benefits-RAOC-RIA5 base · 17 adj
Trustmark Health Benefits
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2020-11-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 140% of Medicare lab
  3. 140% of Medicare drug
  4. 140% of Medicare DME
  5. 140% 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
United-Healthcare-ECFOI8 base · 18 adj
United Healthcare
Profee · ECFOI · 2020-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare DME (rates as of 2012-04-01)
  3. 100% of Medicare drug (rates as of 2012-04-01)
  4. 100% of Medicare lab (rates as of 2012-04-01)
  5. 100% of Medicare RVU (rates as of 2012-04-01)
  6. 100% of the Fixed-Fees-Contractor-Rates fee schedule
  7. 100% of the MAC-RadioPharm-Fixed-Fees fee schedule
  8. 100% of the MAC-Invoice-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. 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. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
United-Healthcare-IMI9 base · 17 adj
United Healthcare, United Healthcare Medicare
Profee · IMI · 2020-01-01 → 2024-08-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. computed expression (operands follow)
  4. 100% of Medicare RVU (rates as of 2014-01-01)
  5. Multiply 1% of the Fixed-Fees-Percentage fee schedule
  6. 100% of Medicare DME (rates as of 2014-01-01)
  7. 100% of Medicare drug (rates as of 2014-01-01)
  8. 80% of Medicare RVU (rates as of 2014-01-01)
  9. 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
United-Healthcare-IMI7 base · 18 adj
United Healthcare
Profee · IMI · 2024-09-01 → 2025-08-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 100% of Medicare DME (rates as of 2020-04-01)
  4. 100% of Medicare drug (rates as of 2020-04-01)
  5. 100% of Medicare lab (rates as of 2020-04-01)
  6. 100% of Medicare RVU (rates as of 2020-04-01)
  7. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  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
United-Healthcare-IMI7 base · 19 adj
United Healthcare
Profee · IMI · 2025-09-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 105% of Medicare DME (rates as of 2020-04-01)
  4. 105% of Medicare drug (rates as of 2020-04-01)
  5. 105% of Medicare lab (rates as of 2020-04-01)
  6. 105% of Medicare RVU (rates as of 2020-04-01)
  7. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  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. modifier QZ present → 85% of the running amount
  19. cap each charge and the account total at 100% of billed charges
United-Healthcare-IMI7 base · 17 adj
United Healthcare Medicare
Profee · IMI · 2020-01-01 → 2024-02-29
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 80% of Medicare RVU (rates as of 2014-01-01)
  4. 100% of Medicare DME (rates as of 2014-01-01)
  5. 100% of Medicare drug (rates as of 2014-01-01)
  6. 100% of Medicare lab (rates as of 2014-01-01)
  7. 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
United-Healthcare-IMI8 base · 17 adj
United Healthcare Medicare
Profee · IMI · 2020-01-01 → 2024-02-29
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. computed expression (operands follow)
  4. 100% of Medicare RVU
  5. Multiply 1% of the Fixed-Fees-Percentage fee schedule
  6. 100% of Medicare DME
  7. 100% of Medicare RVU
  8. 50% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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
United-Healthcare-MICTIC5 base · 17 adj
United Healthcare
Profee · MICTIC · 2018-10-01 → 2024-11-30
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 150% of Medicare DME (rates as of 2015-01-01)
  3. 150% of Medicare drug (rates as of 2015-01-01)
  4. 150% of Medicare lab (rates as of 2015-01-01)
  5. 150% of Medicare RVU (rates as of 2015-01-01)
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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
United-Healthcare-MICTIC8 base · 18 adj
United Healthcare
Profee · MICTIC · 2024-12-01 → 2025-11-30
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 100% of Medicare anesthesia (rates as of 2020-01-01)
  4. 40% of Medicare DME (rates as of 2020-01-01)
  5. 100% of Medicare drug
  6. 60% of Medicare lab (rates as of 2020-01-01)
  7. 160% of Medicare RVU (rates as of 2020-01-01)
  8. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. Medicare bilateral-surgery adjustment
  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
United-Healthcare-MICTIC8 base · 18 adj
United Healthcare
Profee · MICTIC · 2025-12-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 100% of Medicare anesthesia (rates as of 2020-01-01)
  4. 40% of Medicare DME (rates as of 2020-01-01)
  5. 100% of Medicare drug
  6. 60% of Medicare lab (rates as of 2020-01-01)
  7. 161.6% of Medicare RVU (rates as of 2020-01-01)
  8. 20% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
United-Healthcare-Medicare-ECFOI8 base · 17 adj
United Healthcare Dual, United Healthcare Medicare
Profee · ECFOI · 2018-10-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 95% of Medicare DME
  3. 95% of Medicare drug
  4. 95% of Medicare lab
  5. 95% of Medicare RVU
  6. 100% of the Fixed-Fees-Contractor-Rates fee schedule
  7. 100% of the MAC-RadioPharm-Fixed-Fees fee schedule
  8. 100% of the MAC-Invoice-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. 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
United-Healthcare-Medicare-IMI6 base · 17 adj
United Healthcare Dual, United Healthcare Medicare
Profee · IMI · 2024-09-01 → 2025-08-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
  3. 90% of Medicare DME
  4. 90% of Medicare drug
  5. 90% of Medicare lab
  6. 90% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — 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
United-Healthcare-Medicare-IMI6 base · 17 adj
United Healthcare Dual, United Healthcare Medicare
Profee · IMI · 2025-09-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the 100% of Humana 201-544 Fee Schedule - Drugs & Biologicals fee schedule
  3. 100% of Medicare DME
  4. 100% of Medicare drug
  5. 100% of Medicare lab
  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. 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
United-Healthcare-Medicare-MICTIC6 base · 17 adj
United Healthcare Dual, United Healthcare Medicare
Profee · MICTIC · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare DME
  3. 100% of Medicare drug
  4. 100% of Medicare lab
  5. 100% of Medicare RVU
  6. 100% of the Fixed-Fees-Contractor-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — 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
United-Healthcare-RAOC-RIA11 base · 18 adj
United Healthcare
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2021-11-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 100% of Medicare anesthesia (rates as of 2020-01-01)
  4. computed expression (operands follow)
  5. 100% of Medicare RVU (rates as of 2020-01-01)
  6. Multiply 1% of the Fixed-Fees-Percentage fee schedule
  7. 60% of Medicare DME (FL, rates as of 2020-01-01)
  8. 100% of Medicare drug
  9. 60% of Medicare lab (rates as of 2020-01-01)
  10. 150% of Medicare RVU (rates as of 2020-01-01)
  11. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. modifier 22 present → 135% of the running amount
  5. modifier 50 present → 150% of the running amount
  6. modifier 52 present → 50% of the running amount
  7. modifier 54 present → 80% of the running amount
  8. modifier 62 present → 62.5% of the running amount
  9. modifier 78 present → 70% of the running amount
  10. modifier 80 present → 16% of the running amount
  11. modifier 81 present → 16% of the running amount
  12. modifier 82 present → 16% of the running amount
  13. modifier AS present → 14% of the running amount
  14. modifier QY present → 50% of the running amount
  15. modifier QK present → 50% of the running amount
  16. modifier QX present → 50% of the running amount
  17. modifier QZ present → 85% of the running amount
  18. cap each charge and the account total at 100% of billed charges
United-Healthcare-RAOC-RIA8 base · 17 adj
United Healthcare
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2021-11-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  3. 100% of Medicare anesthesia (rates as of 2020-01-01)
  4. 60% of Medicare DME (FL, rates as of 2020-01-01)
  5. 100% of Medicare drug
  6. 60% of Medicare lab (rates as of 2020-01-01)
  7. 150% of Medicare RVU (rates as of 2020-01-01)
  8. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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
VA-Community-Care-Network-IMI7 base · 17 adj
VA Community Care Network
Profee · IMI · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of the Curative - MRI/MRA/CT Scan/PET fee schedule
  7. 100% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  4. 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
VA-Community-Care-Network-RAOC-RIA6 base · 17 adj
VA Community Care Network
Profee · RAOC / RIA, RAOC / RIA - Daytona, RAOC / RIA - Ocala · 2021-08-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of the Curative - MRI/MRA/CT Scan/PET 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. 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
WellMed-Medicare-ECFOI-IMI-MICTIC6 base · 17 adj
WellMed
Profee · ECFOI, IMI, MICTIC · 2026-01-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
  6. 100% of the Curative - MRI/MRA/CT Scan/PET 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
Wellcare-IMI6 base · 17 adj
WellCare
Profee · IMI · 2024-06-01 → 2999-12-31
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 65% of Medicare lab
  3. 65% of Medicare drug
  4. 65% of Medicare DME
  5. 65% of Medicare RVU
  6. 100% of the Curative - MRI/MRA/CT Scan/PET 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

Cannot fire (3)

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

70% Medicare · no contract map6 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 70% of Medicare lab
  3. 70% of Medicare drug
  4. 70% of Medicare DME
  5. 70% of Medicare RVU
  6. 70% of the Curative - MRI/MRA/CT Scan/PET 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. Medicare OPPS cap
  18. cap each charge and the account total at 100% of billed charges
Cigna-MICTIC-Backup · no contract map18 base · 17 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of the Fixed-Fees-Carveout fee schedule
  3. 100% of Medicare DME (rates as of 2013-01-01)
  4. 100% of Medicare drug (rates as of 2013-01-01)
  5. 100% of Medicare lab (rates as of 2013-01-01)
  6. 100% of Medicare RVU (rates as of 2013-01-01)
  7. 100% of Medicare RVU (rates as of 2014-01-01)
  8. 100% of Medicare RVU (rates as of 2015-01-01)
  9. 100% of Medicare RVU (rates as of 2016-01-01)
  10. 100% of Medicare RVU (rates as of 2017-01-01)
  11. 100% of Medicare RVU (rates as of 2018-01-01)
  12. 100% of Medicare RVU (rates as of 2019-01-01)
  13. 100% of Medicare RVU (rates as of 2020-01-01)
  14. 100% of Medicare RVU (rates as of 2021-01-01)
  15. 100% of Medicare RVU (rates as of 2022-01-01)
  16. 100% of Medicare RVU (rates as of 2023-01-01)
  17. 100% of Medicare RVU (rates as of 2024-01-01)
  18. 45% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction
  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
Freedom-Health-Medicare-MICTIC · no contract map6 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 0% of the Non-Priced-Codes fee schedule
  2. 100% of Medicare DME
  3. 100% of Medicare drug
  4. 100% of Medicare lab
  5. 100% of Medicare RVU
  6. 100% of the Fixed-Fees-Contractor-Rates fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — 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. Medicare OPPS cap
  18. cap each charge and the account total at 100% of billed charges