Customer detail

StrideCare

38
live contracts
3
cannot fire
19
calc types
2
SQL bodies
1
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment485
MedicareMultipleProcedureAdjustment37
MedicareMultipleEndoscopyAdjustment37
MedicareMultipleRadiologyAdjustment37
FlatFee36
LesserOfAdjustment36
PercentOfFees35
MidLevelProviderAdjustment33
MedicareDME6
MedicareLab6
MedicareDrug6
MedicareRVU6
MedicareASC3
FlatPercentOfCharges3
MedicareBilateralSurgeryAdjustment3
ChargeLevelSqlAdjustment2
SqlExpression2
MedicareAnesthesia2
PercentOfCharges1

Contracts

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

Aetna-Medicare-Profee2 base · 18 adj
Aetna Medicare
Profee · Austin, San Antonio · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present; ChargeCoverage NC is present
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges — when ChargeCoverage NC is absent
Aetna-Profee4 base · 18 adj
Aetna
Profee · Austin, San Antonio · 2022-01-01 → 2026-06-30
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Aetna-Dallas-Profee fee schedule — when FacilityGroup in Dallas
  3. 100% of the Aetna-NonDallas-Profee fee schedule
  4. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges
Aetna-Profee-20262 base · 18 adj
Aetna
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Aetna-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges
Ambetter5 base · 18 adj
Ambetter
Profee · all facilities · 2022-01-01 → 2026-06-30
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 115% of Medicare lab
  3. 115% of Medicare drug
  4. 115% of Medicare DME
  5. 115% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 45% of billed charges
Ambetter-Profee-20262 base · 18 adj
Ambetter
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Ambetter-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 45% of billed charges
BCBS-Anthem-Profee2 base · 18 adj
BCBS Anthem
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the BCBS-Anthem-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges
BCBS-BAV-Profee2 base · 18 adj
Blue Cross Blue Shield BAV
Profee · all facilities · 2024-02-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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-HMO-Profee2 base · 18 adj
Blue Cross Blue Shield HMO
Profee · all facilities · 2024-02-01 → 2026-06-30
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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-HMO-Profee-20262 base · 18 adj
Blue Cross Blue Shield HMO
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the BCBS-HMO-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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-PPO-Profee2 base · 18 adj
Blue Cross Blue Shield PPO
Profee · all facilities · 2024-02-01 → 2026-06-30
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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-PPO-Profee-20262 base · 18 adj
Blue Cross Blue Shield PPO
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the BCBS-PPO-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
Baylor-Scott-and-White-Profee2 base · 18 adj
Baylor Scott and White
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the BaylorScottandWhite-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges
Charges1 base · 0 adj
Charges
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Chargemaster fee schedule
Cigna-LocalPlus-Profee-NorthTexas3 base · 18 adj
Cigna LocalPlus
Profee · Austin, Houston, San Antonio, ASC, Clinic, Hospital · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Mid-Level-Providers fee schedule
  3. percent-of-charges, rate read from the None schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  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
Cigna-Profee-20262 base · 17 adj
Cigna
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Cigna-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  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-Profee-North Texas7 base · 18 adj
Cigna
Profee · Dallas, ASC, Clinic, Hospital · 2022-01-01 → 2026-06-30
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Fixed-Fees-Podiatry fee schedule — when ProviderType DPM is present
  3. 100% of the Fixed-Fees fee schedule — when ProviderType MD is present
  4. 100% of the Fixed-Fees fee schedule — when ProviderType DO is present
  5. 100% of Medicare anesthesia
  6. 100% of the Mid-Level-Providers fee schedule
  7. 60% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  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
Cigna-Profee-South Texas4 base · 18 adj
Cigna
Profee · Austin, Houston, San Antonio, ASC, Clinic, Hospital · 2022-01-01 → 2026-06-30
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of Medicare anesthesia
  3. 100% of the Fixed-Fees-STX fee schedule
  4. 60% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  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
Humana-Medicare-Profee2 base · 18 adj
Humana Medicare
Profee · Dallas, San Antonio, Clinic · 2022-12-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Humana-Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
Humana-Profee2 base · 18 adj
Humana
Profee · Dallas, Houston, San Antonio · 2022-12-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Humana-Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
Humana-Profee-Austin5 base · 18 adj
Humana
Profee · Austin · 2022-12-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of Medicare RVU (rates as of 2006-01-01)
  3. 100% of Medicare drug (rates as of 2006-01-01)
  4. 100% of Medicare DME (rates as of 2006-01-01)
  5. 100% of Medicare lab
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
Medicaid1 base · 0 adj
Medicaid
Profee · all facilities · 2022-04-17 → 2999-12-31
Base terms — first match wins
  1. custom SQL — Looks up a Texas Medicaid fee for a procedure/modifier from the customer's own state-Medicaid reference table, taking the most recently effective rate before the service date, optionally further narrowed by patient age band, then multiplies by units.
Medicare5 base · 18 adj
Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Blue Cross Blue Shield Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of Medicare lab (TX)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (TX)
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges
Medicare-ASC2 base · 19 adj
Medicare
Facility · ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 100% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50%
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
  19. cap each charge and the account total at 100% of billed charges
Meritain-Profee2 base · 18 adj
Meritain
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Meritain-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges
Molina-Profee2 base · 18 adj
Molina
Profee · Dallas, Houston, San Antonio · 2026-07-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Molina-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
Multiplan-Facility3 base · 18 adj
Multiplan
Facility · ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when NoncoverageStatus Noncovered is present
  2. 275% of Medicare ASC
  3. 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. Medicare bilateral-surgery adjustment
  5. mid-level provider reduction (by NUCC taxonomy)
  6. modifier 22 present → 135% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. custom SQL — Allocates a global-surgery-period allowed amount to its post-operative portion: pulls a procedure's POST_OP percentage and GLOB_DAYS (global period length) from Medicare RVU reference data and returns Allowed / GlobalDays * PostOpRate — i.e. a per-day post-op share of the total global allowed amount. — when Modifier 55 is present
  9. modifier 54 present → 80% of the running amount
  10. modifier 62 present → 62.5% of the running amount
  11. modifier 78 present → 70% of the running amount
  12. modifier 80 present → 16% of the running amount
  13. modifier 81 present → 16% of the running amount
  14. modifier 82 present → 16% of the running amount
  15. modifier AS present → 14% of the running amount
  16. modifier QY present → 50% of the running amount
  17. modifier QK present → 50% of the running amount
  18. modifier QX present → 50% of the running amount
Oscar-Profee2 base · 18 adj
Oscar
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Oscar-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges
PHCS-First-Health-Profee2 base · 18 adj
PHCS First Health
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the PHCSFirstHealth-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges
Self-Pay1 base · 1 adj
Self Pay
Profee · all facilities · 2022-04-21 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fees-Self-Pay fee schedule
Adjustments — all apply, in order
  1. Medicare bilateral-surgery adjustment
United-Healthcare2 base · 19 adj
United Healthcare
Profee · all facilities · 2025-02-27 → 2026-06-30
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the United-Healthcare-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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-Medicare-Profee2 base · 19 adj
United Healthcare Medicare
Profee · all facilities · 2025-02-27 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 45% of billed charges
UnitedHealthcare-Profee-20262 base · 19 adj
United Healthcare
Profee · Austin, Dallas, Houston, San Antonio · 2026-07-01 → 2099-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the United-Healthcare-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
WellCare-Profee4 base · 18 adj
WellCare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare lab (TX)
  2. 100% of Medicare drug
  3. 100% of Medicare DME (TX)
  4. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
Wellmed-Humana-Medicare-Profee2 base · 18 adj
Wellmed Humana Medicare
Profee · Dallas, San Antonio · 2022-12-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Humana-Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 45% of billed charges
Wellmed-UHC-Medicare-Profee2 base · 18 adj
Wellmed UHC Medicare
Profee · all facilities · 2025-02-27 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 45% of billed charges
Wellpoint-Medicaid2 base · 0 adj
Wellpoint Medicaid
Profee · all facilities · 2022-04-17 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. custom SQL — Looks up a Texas Medicaid fee for a procedure/modifier from the customer's own state-Medicaid reference table, taking the most recently effective rate before the service date, optionally further narrowed by patient age band, then multiplies by units.
Wellpoint-Medicare-Profee5 base · 18 adj
Wellpoint Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of Medicare lab (TX)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (TX)
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
Wellpoint-Profee5 base · 18 adj
Wellpoint
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of Medicare lab (TX)
  3. 100% of Medicare drug
  4. 100% of Medicare DME (TX)
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. modifier 54 present → 80% of the running amount
  9. modifier 62 present → 62.5% of the running amount
  10. modifier 78 present → 70% of the running amount
  11. modifier 80 present → 16% of the running amount
  12. modifier 81 present → 16% of the running amount
  13. modifier 82 present → 16% of the running amount
  14. modifier AS present → 14% of the running amount
  15. modifier QY present → 50% of the running amount
  16. modifier QK present → 50% of the running amount
  17. modifier QX present → 50% of the running amount
  18. cap each charge and the account total at 100% of billed charges

Cannot fire (3)

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

NonDallas-Aetna-Profee · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Aetna-NonDallas-Profee fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 85% of billed charges
Superior-ASC · no contract map1 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 120% of Medicare ASC
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when Modifier MV is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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
Wellmed · no contract map2 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. flat $50 — when ProcedureCode A6533 is present
  2. 100% of the Fixed-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-procedure reduction — base codes 2; pays 100/50% — when ToBeScheduledEpisode TO BE SCHEDULED is absent
  2. Medicare multiple-endoscopy reduction
  3. Medicare multiple-radiology reduction — base codes 4
  4. mid-level provider reduction (by NUCC taxonomy)
  5. modifier 22 present → 135% of the running amount
  6. modifier 50 present → 150% of the running amount
  7. modifier 52 present → 50% of the running amount
  8. 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 45% of billed charges