Customer detail

SWOrofacial

10
live contracts
0
cannot fire
14
calc types
3
SQL bodies
0
of those blocked
1
map conflicts

Methodology mix

ModifierAdjustment104
PercentOfFees20
MultipleProcedureAdjustment8
LesserOfAdjustment8
MedicareMultipleEndoscopyAdjustment8
MedicareMultipleRadiologyAdjustment8
MidLevelProviderAdjustment8
SqlExpression4
FlatFee1
MedicareLab1
MedicareDrug1
MedicareRVU1
MedicareDME1
FlatPercentOfCharges1

Contracts

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

Aetna-Profee3 base · 18 adj
Aetna
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Self-Pay-Profee fee schedule — when ChargeCoverage NC is present
  2. 100% of the Aetna-Facility-Profee-Fees fee schedule — when ChargeCoverage NC is absent; FacilityType in ASC, Home, Hospital
  3. 100% of the Aetna-NonFacility-Profee-Fees fee schedule — when ChargeCoverage NC is absent; FacilityType in Clinic
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50% — when ChargeCoverage NC is absent
  2. Medicare multiple-endoscopy reduction — when ChargeCoverage NC is absent
  3. Medicare multiple-radiology reduction — base codes 4 — when ChargeCoverage NC is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ChargeCoverage NC is absent
  5. modifier 22 present → 135% of the running amount — when ChargeCoverage NC is absent
  6. modifier 50 present → 150% of the running amount — when ChargeCoverage NC is absent
  7. modifier 52 present → 50% of the running amount — when ChargeCoverage NC is absent
  8. modifier 54 present → 80% of the running amount — when ChargeCoverage NC is absent
  9. modifier 62 present → 62.5% of the running amount — when ChargeCoverage NC is absent
  10. modifier 78 present → 70% of the running amount — when ChargeCoverage NC is absent
  11. modifier 80 present → 16% of the running amount — when ChargeCoverage NC is absent
  12. modifier 81 present → 16% of the running amount — when ChargeCoverage NC is absent
  13. modifier 82 present → 16% of the running amount — when ChargeCoverage NC is absent
  14. modifier AS present → 14% of the running amount — when ChargeCoverage NC is absent
  15. modifier QY present → 50% of the running amount — when ChargeCoverage NC is absent
  16. modifier QK present → 50% of the running amount — when ChargeCoverage NC is absent
  17. modifier QX present → 50% of the running amount — when ChargeCoverage NC is absent
  18. cap each charge and the account total at 100% of billed charges — when ChargeCoverage NC is absent
Blue Cross Blue Shield-Profee4 base · 18 adj
Blue Cross Blue Shield, Southwest Service Administrators
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Self-Pay-Profee fee schedule — when ChargeCoverage NC is present
  2. 100% of the Blue Cross Blue Shield-Facility Profee fee schedule — when Provider BCC00-AdvancedMD is present
  3. 100% of the Blue Cross Blue Shield-Facility Profee fee schedule — when Provider BCCEM-AdvancedMD is present
  4. 100% of the Blue Cross Blue Shield-Profee fee schedule
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50% — when ChargeCoverage NC is absent
  2. Medicare multiple-endoscopy reduction — when ChargeCoverage NC is absent
  3. Medicare multiple-radiology reduction — base codes 4 — when ChargeCoverage NC is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ChargeCoverage NC is absent
  5. modifier 22 present → 135% of the running amount — when ChargeCoverage NC is absent
  6. modifier 50 present → 150% of the running amount — when ChargeCoverage NC is absent
  7. modifier 52 present → 50% of the running amount — when ChargeCoverage NC is absent
  8. modifier 54 present → 80% of the running amount — when ChargeCoverage NC is absent
  9. modifier 62 present → 62.5% of the running amount — when ChargeCoverage NC is absent
  10. modifier 78 present → 70% of the running amount — when ChargeCoverage NC is absent
  11. modifier 80 present → 16% of the running amount — when ChargeCoverage NC is absent
  12. modifier 81 present → 16% of the running amount — when ChargeCoverage NC is absent
  13. modifier 82 present → 16% of the running amount — when ChargeCoverage NC is absent
  14. modifier AS present → 14% of the running amount — when ChargeCoverage NC is absent
  15. modifier QY present → 50% of the running amount — when ChargeCoverage NC is absent
  16. modifier QK present → 50% of the running amount — when ChargeCoverage NC is absent
  17. modifier QX present → 50% of the running amount — when ChargeCoverage NC is absent
  18. cap each charge and the account total at 100% of billed charges — when ChargeCoverage NC is absent
Charges-Profee1 base · 0 adj
Charges
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Chargemaster-Profee fee schedule
Cigna Medicare-Profee3 base · 18 adj
Cigna Medicare
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Self-Pay-Profee fee schedule — when ChargeCoverage NC is present
  2. 100% of the Cigna-NonFacility-Profee fee schedule — when ChargeCoverage NC is absent
  3. custom SQL — Prices HCPCS E0486 (oral sleep-apnea device) at 50% of billed charges, with no date gate. — when ChargeCoverage NC is absent
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50% — when ChargeCoverage NC is absent
  2. Medicare multiple-endoscopy reduction — when ChargeCoverage NC is absent
  3. Medicare multiple-radiology reduction — base codes 4 — when ChargeCoverage NC is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ChargeCoverage NC is absent
  5. modifier 22 present → 135% of the running amount — when ChargeCoverage NC is absent
  6. modifier 50 present → 150% of the running amount — when ChargeCoverage NC is absent
  7. modifier 52 present → 50% of the running amount — when ChargeCoverage NC is absent
  8. modifier 54 present → 80% of the running amount — when ChargeCoverage NC is absent
  9. modifier 62 present → 62.5% of the running amount — when ChargeCoverage NC is absent
  10. modifier 78 present → 70% of the running amount — when ChargeCoverage NC is absent
  11. modifier 80 present → 16% of the running amount — when ChargeCoverage NC is absent
  12. modifier 81 present → 16% of the running amount — when ChargeCoverage NC is absent
  13. modifier 82 present → 16% of the running amount — when ChargeCoverage NC is absent
  14. modifier AS present → 14% of the running amount — when ChargeCoverage NC is absent
  15. modifier QY present → 50% of the running amount — when ChargeCoverage NC is absent
  16. modifier QK present → 50% of the running amount — when ChargeCoverage NC is absent
  17. modifier QX present → 50% of the running amount — when ChargeCoverage NC is absent
  18. cap each charge and the account total at 100% of billed charges — when ChargeCoverage NC is absent
Cigna Profee2 base · 18 adj
Cigna
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Self-Pay-Profee fee schedule — when ChargeCoverage NC is present
  2. 100% of the Cigna Clinic fee schedule — when ChargeCoverage NC is absent
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50% — when ChargeCoverage NC is absent
  2. Medicare multiple-endoscopy reduction — when ChargeCoverage NC is absent
  3. Medicare multiple-radiology reduction — base codes 4 — when ChargeCoverage NC is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ChargeCoverage NC is absent
  5. modifier 22 present → 135% of the running amount — when ChargeCoverage NC is absent
  6. modifier 50 present → 150% of the running amount — when ChargeCoverage NC is absent
  7. modifier 52 present → 50% of the running amount — when ChargeCoverage NC is absent
  8. modifier 54 present → 80% of the running amount — when ChargeCoverage NC is absent
  9. modifier 62 present → 62.5% of the running amount — when ChargeCoverage NC is absent
  10. modifier 78 present → 70% of the running amount — when ChargeCoverage NC is absent
  11. modifier 80 present → 16% of the running amount — when ChargeCoverage NC is absent
  12. modifier 81 present → 16% of the running amount — when ChargeCoverage NC is absent
  13. modifier 82 present → 16% of the running amount — when ChargeCoverage NC is absent
  14. modifier AS present → 14% of the running amount — when ChargeCoverage NC is absent
  15. modifier QY present → 50% of the running amount — when ChargeCoverage NC is absent
  16. modifier QK present → 50% of the running amount — when ChargeCoverage NC is absent
  17. modifier QX present → 50% of the running amount — when ChargeCoverage NC is absent
  18. cap each charge and the account total at 100% of billed charges — when ChargeCoverage NC is absent
Medicare6 base · 18 adj
Blue Cross Blue Shield Medicare, Medicare
Profee · all facilities · 2022-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Self-Pay-Profee fee schedule — when ChargeCoverage NC is present
  2. custom SQL — Hardcoded flat price of $1,719.11 for HCPCS E0486 (an oral device/appliance code), with the code resolved via the customer's ChargeType mapping table. — when ChargeCoverage NC is absent
  3. 100% of Medicare lab — when ChargeCoverage NC is absent
  4. 100% of Medicare drug — when ChargeCoverage NC is absent
  5. 100% of Medicare DME — when ChargeCoverage NC is absent
  6. 100% of Medicare RVU — when ChargeCoverage NC is absent
Adjustments — all apply, in order
  1. modifier 50 present → 150% of the running amount — when ChargeCoverage NC is absent
  2. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50% — when ChargeCoverage NC is absent
  3. Medicare multiple-endoscopy reduction — when ChargeCoverage NC is absent
  4. Medicare multiple-radiology reduction — base codes 4 — when ChargeCoverage NC is absent
  5. mid-level provider reduction (by NUCC taxonomy) — when ChargeCoverage NC is absent
  6. modifier 22 present → 135% of the running amount — when ChargeCoverage NC is absent
  7. modifier 52 present → 50% of the running amount — when ChargeCoverage NC is absent
  8. modifier 54 present → 80% of the running amount — when ChargeCoverage NC is absent
  9. modifier 62 present → 62.5% of the running amount — when ChargeCoverage NC is absent
  10. modifier 78 present → 70% of the running amount — when ChargeCoverage NC is absent
  11. modifier 80 present → 16% of the running amount — when ChargeCoverage NC is absent
  12. modifier 81 present → 16% of the running amount — when ChargeCoverage NC is absent
  13. modifier 82 present → 16% of the running amount — when ChargeCoverage NC is absent
  14. modifier AS present → 14% of the running amount — when ChargeCoverage NC is absent
  15. modifier QY present → 50% of the running amount — when ChargeCoverage NC is absent
  16. modifier QK present → 50% of the running amount — when ChargeCoverage NC is absent
  17. modifier QX present → 50% of the running amount — when ChargeCoverage NC is absent
  18. cap each charge and the account total at 100% of billed charges — when ChargeCoverage NC is absent
Mutiplan-Profee3 base · 18 adj
Aetna
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Self-Pay-Profee fee schedule — when ChargeCoverage NC is present
  2. 100% of the Multiplan-Profee fee schedule — when ChargeCoverage NC is absent; FacilityType in Clinic
  3. 60% of billed charges
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50% — when ChargeCoverage NC is absent
  2. Medicare multiple-endoscopy reduction — when ChargeCoverage NC is absent
  3. Medicare multiple-radiology reduction — base codes 4 — when ChargeCoverage NC is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ChargeCoverage NC is absent
  5. modifier 22 present → 135% of the running amount — when ChargeCoverage NC is absent
  6. modifier 50 present → 150% of the running amount — when ChargeCoverage NC is absent
  7. modifier 52 present → 50% of the running amount — when ChargeCoverage NC is absent
  8. modifier 54 present → 80% of the running amount — when ChargeCoverage NC is absent
  9. modifier 62 present → 62.5% of the running amount — when ChargeCoverage NC is absent
  10. modifier 78 present → 70% of the running amount — when ChargeCoverage NC is absent
  11. modifier 80 present → 16% of the running amount — when ChargeCoverage NC is absent
  12. modifier 81 present → 16% of the running amount — when ChargeCoverage NC is absent
  13. modifier 82 present → 16% of the running amount — when ChargeCoverage NC is absent
  14. modifier AS present → 14% of the running amount — when ChargeCoverage NC is absent
  15. modifier QY present → 50% of the running amount — when ChargeCoverage NC is absent
  16. modifier QK present → 50% of the running amount — when ChargeCoverage NC is absent
  17. modifier QX present → 50% of the running amount — when ChargeCoverage NC is absent
  18. cap each charge and the account total at 100% of billed charges — when ChargeCoverage NC is absent
Self-Pay-Profee1 base · 0 adj
Self-Pay
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Self-Pay-Profee fee schedule
United Healthcare-Profee4 base · 18 adj
UMR, United Healthcare
Profee · all facilities · 2025-10-01 → 2999-12-31
Base terms — first match wins
  1. flat $0 — when CodeRange in 21110–21110
  2. 100% of the Self-Pay-Profee fee schedule — when ChargeCoverage NC is present
  3. 100% of the United HealthCare Facility Profee Fees fee schedule — when ChargeCoverage NC is absent
  4. custom SQL — Hardcoded rule: for HCPCS E0486 (oral device/appliance) only, allowed amount is 40% of billed charge; every other procedure code yields no amount. — when ChargeCoverage NC is absent
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50% — when ChargeCoverage NC is absent
  2. Medicare multiple-endoscopy reduction — when ChargeCoverage NC is absent
  3. Medicare multiple-radiology reduction — base codes 4 — when ChargeCoverage NC is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ChargeCoverage NC is absent
  5. modifier 22 present → 135% of the running amount — when ChargeCoverage NC is absent
  6. modifier 50 present → 150% of the running amount — when ChargeCoverage NC is absent
  7. modifier 52 present → 50% of the running amount — when ChargeCoverage NC is absent
  8. modifier 54 present → 80% of the running amount — when ChargeCoverage NC is absent
  9. modifier 62 present → 62.5% of the running amount — when ChargeCoverage NC is absent
  10. modifier 78 present → 70% of the running amount — when ChargeCoverage NC is absent
  11. modifier 80 present → 16% of the running amount — when ChargeCoverage NC is absent
  12. modifier 81 present → 16% of the running amount — when ChargeCoverage NC is absent
  13. modifier 82 present → 16% of the running amount — when ChargeCoverage NC is absent
  14. modifier AS present → 14% of the running amount — when ChargeCoverage NC is absent
  15. modifier QY present → 50% of the running amount — when ChargeCoverage NC is absent
  16. modifier QK present → 50% of the running amount — when ChargeCoverage NC is absent
  17. modifier QX present → 50% of the running amount — when ChargeCoverage NC is absent
  18. cap each charge and the account total at 100% of billed charges — when ChargeCoverage NC is absent
UnitedHealthcare-Community-Profee3 base · 18 adj
UHC Community Plan
Profee · all facilities · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Self-Pay-Profee fee schedule — when ChargeCoverage NC is present
  2. 100% of the UHC-Community-Profee fee schedule — when ChargeCoverage NC is absent
  3. custom SQL — Hardcoded rule: for HCPCS E0486 (oral device/appliance) only, allowed amount is 40% of billed charge; every other procedure code yields no amount. — when ChargeCoverage NC is absent
Adjustments — all apply, in order
  1. multiple-procedure reduction (contract rules) — base codes 2; pays 100/50% — when ChargeCoverage NC is absent
  2. Medicare multiple-endoscopy reduction — when ChargeCoverage NC is absent
  3. Medicare multiple-radiology reduction — base codes 4 — when ChargeCoverage NC is absent
  4. mid-level provider reduction (by NUCC taxonomy) — when ChargeCoverage NC is absent
  5. modifier 22 present → 135% of the running amount — when ChargeCoverage NC is absent
  6. modifier 50 present → 150% of the running amount — when ChargeCoverage NC is absent
  7. modifier 52 present → 50% of the running amount — when ChargeCoverage NC is absent
  8. modifier 54 present → 80% of the running amount — when ChargeCoverage NC is absent
  9. modifier 62 present → 62.5% of the running amount — when ChargeCoverage NC is absent
  10. modifier 78 present → 70% of the running amount — when ChargeCoverage NC is absent
  11. modifier 80 present → 16% of the running amount — when ChargeCoverage NC is absent
  12. modifier 81 present → 16% of the running amount — when ChargeCoverage NC is absent
  13. modifier 82 present → 16% of the running amount — when ChargeCoverage NC is absent
  14. modifier AS present → 14% of the running amount — when ChargeCoverage NC is absent
  15. modifier QY present → 50% of the running amount — when ChargeCoverage NC is absent
  16. modifier QK present → 50% of the running amount — when ChargeCoverage NC is absent
  17. modifier QX present → 50% of the running amount — when ChargeCoverage NC is absent
  18. cap each charge and the account total at 100% of billed charges — when ChargeCoverage NC is absent