Customer detail

USDH

37
live contracts
2
cannot fire
16
calc types
0
SQL bodies
0
of those blocked
0
map conflicts

Methodology mix

ModifierAdjustment495
PercentOfFees64
MedicareRVU58
MedicareDrug38
LesserOfAdjustment38
MedicareMultipleEndoscopyAdjustment38
MedicareMultipleRadiologyAdjustment38
MedicareMultipleProcedureAdjustment37
MidLevelProviderAdjustment37
MedicareAnesthesia19
MedicareLab17
MedicareDME17
CalculationBuilder5
FlatFee4
FlatPercentOfCharges2
MultipleProcedureAdjustment1

Contracts

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

100% Medicare Rate (Payer Medicare Products)5 base · 18 adj
Aetna Medicare
Profee · RGAL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
110% Medicare Rates4 base · 18 adj
PA Health and Wellness Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 110% of Medicare lab
  2. 110% of Medicare drug
  3. 110% of Medicare DME
  4. 110% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Charges1 base · 0 adj
Charges
Facility, Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Flat-Fees fee schedule
DCDC-Aetna HMO Profees3 base · 18 adj
Aetna-HMO
Profee · DCDC · 2016-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 100% of the Carveouts fee schedule
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
DCDC-Aetna PPO Profees3 base · 18 adj
Aetna, Aetna-PPO
Profee · DCDC · 2016-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 100% of the Carveouts fee schedule
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
DCDC-Amerihealth Caritas Facility Profees2 base · 18 adj
Amerihealth Caritas
Profee · DCDC, ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 100% of the Facility-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
DCDC-Amerihealth Caritas Profees2 base · 18 adj
Amerihealth Caritas
Profee · DCDC, Clinic · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
DCDC-Cigna Profees2 base · 18 adj
Cigna
Profee · DCDC · 2016-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
DE Medicaid - Profees3 base · 18 adj
Medicaid
Profee · DE · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Flat-Fees fee schedule
  2. 100% of the Profee-Fees fee schedule
  3. 100% of Medicare drug — when CPTCategories J-Codes is present ⚠︎ named “106% Medicare Drug ASP for J-Codes” but configured at 100%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
DE-First-Health1 base · 18 adj
DE First Health
Profee · DCDC, Clinic · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 115% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
DE-First-Health-Facility-Profees1 base · 18 adj
DE First Health
Profee · DCDC, ASC, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 115% of the Facility-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark ACA (7.01.25)14 base · 18 adj
Highmark ACA
Profee · DCDC, RGAL · 2025-07-01 → 2026-06-30
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 117.52% of Medicare lab (rates as of 2021-01-01)
  4. 97.92% of Medicare drug (rates as of 2021-01-01) — when CPTCategories J-Codes is present
  5. 301.89% of Medicare drug — when ProcedureCode Q5103 is present
  6. 147.17% of Medicare drug — when ProcedureCode Q5121 is present
  7. 80% of Medicare drug — when CPTCategories Q-Codes is present
  8. 80% of Medicare DME (rates as of 2021-01-01)
  9. 156.64% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Surgery is present
  10. 117.44% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Evaluation & Management is present
  11. 225.2% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Anesthesia is present
  12. 146.96% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories G-Codes is present
  13. 117.44% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Pathology & Laboratory is present
  14. 127.28% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Radiology is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark ACA (7.01.26)14 base · 18 adj
Highmark ACA
Profee · DCDC, RGAL · 2026-07-01 → 2027-06-30
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 122.24% of Medicare lab (rates as of 2021-01-01)
  4. 101.84% of Medicare drug (rates as of 2021-01-01) — when CPTCategories J-Codes is present
  5. 301.89% of Medicare drug — when ProcedureCode Q5103 is present ⚠︎ named “400% of Current Medicare ASP Code Q5103” but configured at 301.89%
  6. 147.17% of Medicare drug — when ProcedureCode Q5121 is present
  7. 80% of Medicare drug — when CPTCategories Q-Codes is present
  8. 80% of Medicare DME (rates as of 2021-01-01)
  9. 162.88% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Surgery is present
  10. 122.16% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Evaluation & Management is present
  11. 234.24% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Anesthesia is present
  12. 152.88% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories G-Codes is present
  13. 122.16% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Pathology & Laboratory is present
  14. 132.4% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Radiology is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark ACA (9.20.24)14 base · 18 adj
Highmark ACA
Profee · DCDC, RGAL · 2024-09-20 → 2025-06-30
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 112.96% of Medicare lab (rates as of 2021-01-01)
  4. 93.6% of Medicare drug (rates as of 2021-01-01) — when CPTCategories J-Codes is present
  5. 301.89% of Medicare drug — when ProcedureCode Q5103 is present
  6. 156% of Medicare drug — when ProcedureCode Q5121 is present
  7. 80% of Medicare drug — when CPTCategories Q-Codes is present ⚠︎ named “100% of Then Current ASP” but configured at 80%
  8. 80% of Medicare DME (rates as of 2021-01-01)
  9. 150.64% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Surgery is present
  10. 112.96% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Evaluation & Management is present
  11. 216.56% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Anesthesia is present
  12. 141.28% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories G-Codes is present
  13. 112.96% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Pathology & Laboratory is present
  14. 122.4% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Radiology is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark Commercial (1.1.2022)11 base · 18 adj
Highmark Commercial
Profee · DCDC, RGAL · 2022-01-01 → 2024-09-19
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 132% of Medicare lab (rates as of 2021-01-01)
  3. 103.774% of Medicare drug (rates as of 2021-01-01) — when CPTCategories J-Codes is present ⚠︎ named “110% of 2021 Medicare ASP J-codes” but configured at 103.774%
  4. 113.208% of Medicare drug (rates as of 2021-01-01) — when CPTCategories Q-Codes is present ⚠︎ named “120% of 2021 Medicare ASP Q-codes” but configured at 113.208%
  5. 100% of Medicare DME (rates as of 2021-01-01)
  6. 176% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Surgery is present
  7. 132% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Evaluation & Management is present
  8. 253% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Anesthesia is present
  9. 165% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories G-Codes is present
  10. 132% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Pathology & Laboratory is present
  11. 143% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Radiology is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark Commercial (7.01.25)14 base · 18 adj
Highmark Commercial
Profee · DCDC, RGAL · 2025-07-01 → 2026-06-30
Base terms — first match wins
  1. 281.5% of Medicare anesthesia (rates as of 2021-01-01)
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 146.9% of Medicare lab (rates as of 2021-01-01)
  4. 122.4% of Medicare drug (rates as of 2021-01-01) — when CPTCategories J-Codes is present
  5. 377.358% of Medicare drug — when ProcedureCode Q5103 is present ⚠︎ named “400% of Current Medicare ASP Code Q5103” but configured at 377.358%
  6. 183.962% of Medicare drug — when ProcedureCode Q5121 is present ⚠︎ named “195% of Current Medicare ASP Code Q5121” but configured at 183.962%
  7. 100% of Medicare drug — when CPTCategories Q-Codes is present
  8. 100% of Medicare DME (rates as of 2021-01-01)
  9. 195.8% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Surgery is present
  10. 146.8% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Evaluation & Management is present
  11. 281.5% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Anesthesia is present
  12. 183.7% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories G-Codes is present
  13. 146.8% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Pathology & Laboratory is present
  14. 159.1% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Radiology is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark Commercial (7.01.26)14 base · 18 adj
Highmark Commercial
Profee · DCDC, RGAL · 2026-07-01 → 2027-06-30
Base terms — first match wins
  1. 292.8% of Medicare anesthesia (rates as of 2021-01-01)
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 152.8% of Medicare lab (rates as of 2021-01-01)
  4. 127.3% of Medicare drug (rates as of 2021-01-01) — when CPTCategories J-Codes is present
  5. 377.358% of Medicare drug — when ProcedureCode Q5103 is present ⚠︎ named “400% of Current Medicare ASP Code Q5103” but configured at 377.358%
  6. 183.962% of Medicare drug — when ProcedureCode Q5121 is present ⚠︎ named “195% of Current Medicare ASP Code Q5121” but configured at 183.962%
  7. 100% of Medicare drug — when CPTCategories Q-Codes is present
  8. 100% of Medicare DME (rates as of 2021-01-01)
  9. 203.6% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Surgery is present
  10. 152.7% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Evaluation & Management is present
  11. 292.8% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Anesthesia is present
  12. 191.1% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories G-Codes is present
  13. 152.7% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Pathology & Laboratory is present
  14. 165.5% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Radiology is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark Commercial (9.20.24)14 base · 18 adj
Highmark Commercial
Profee · DCDC, RGAL · 2024-09-20 → 2025-06-30
Base terms — first match wins
  1. 270.7% of Medicare anesthesia (rates as of 2021-01-01)
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 141.2% of Medicare lab (rates as of 2021-01-01)
  4. 117.7% of Medicare drug (rates as of 2021-01-01) — when CPTCategories J-Codes is present ⚠︎ named “117% of Current Medicare ASP” but configured at 117.7%
  5. 377.358% of Medicare drug — when ProcedureCode Q5103 is present ⚠︎ named “400% of Current Medicare ASP Code Q5103” but configured at 377.358%
  6. 183.962% of Medicare drug — when ProcedureCode Q5121 is present ⚠︎ named “195% of Current Medicare ASP Code Q5121” but configured at 183.962%
  7. 100% of Medicare drug — when CPTCategories Q-Codes is present
  8. 100% of Medicare DME (rates as of 2021-01-01)
  9. 188.3% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Surgery is present
  10. 141.2% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Evaluation & Management is present
  11. 270.7% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Anesthesia is present
  12. 176.6% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories G-Codes is present
  13. 141.2% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Pathology & Laboratory is present
  14. 153% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Radiology is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark-BCBS-Health-Options1 base · 18 adj
Highmark BCBS Health Options
Profee · all facilities · 2016-07-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Highmark-Commercial-202110 base · 18 adj
Highmark Commercial
Profee · DCDC, RGAL · 2021-11-11 → 2021-12-31
Base terms — first match wins
  1. 120% of Medicare lab (rates as of 2021-01-01)
  2. 110% of Medicare drug (rates as of 2021-01-01) — when CPTCategories J-Codes is present
  3. 120% of Medicare drug (rates as of 2021-01-01) — when CPTCategories Q-Codes is present
  4. 100% of Medicare DME (rates as of 2021-01-01)
  5. 160% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Surgery is present
  6. 120% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Evaluation & Management is present
  7. 253% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Anesthesia is present
  8. 150% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories G-Codes is present
  9. 120% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Pathology & Laboratory is present
  10. 130% of Medicare RVU (rates as of 2021-01-01) — when CPTCategories Radiology is present
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Medicare5 base · 18 adj
Highmark Medicare, UHC Medicare, World Trade Center
Profee · all facilities · 2023-01-01 → 2999-12-31
UHC Commercial
Profee · DCDC · 2024-10-18 → 2999-12-31
Novitas Medicare, Private Payer Medicare Based Plans, Railroad Medicare
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of Medicare lab
  3. 100% of Medicare drug
  4. 100% of Medicare DME
  5. 100% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
PA Health and Wellness Medicaid - Profees2 base · 18 adj
PA Health and Wellness Medicaid
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 110% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
PA Medicaid - Profees1 base · 18 adj
Medicaid
Profee · PA · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
PHC-Commercial2 base · 18 adj
Preferred Healthcare Commercial
Profee · RGAL · 2024-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL - Highmark Medicare7 base · 18 adj
Highmark Medicare
Profee · RGAL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 100% of Medicare lab
  4. 100% of Medicare drug
  5. 100% of Medicare DME
  6. 100% of Medicare RVU
  7. 100% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL - UPMC CHC2 base · 17 adj
UPMC CHC
Profee · RGAL · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 115% of the Profee-Fees fee schedule ⚠︎ named “100% PA Medicaid Fee Schedule” but configured at 115%
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL - UPMC Commercial Profees7 base · 18 adj
UPMC
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. flat $41.52 — when ProcedureCode Q5121 is present
  3. flat $54.47 — when ProcedureCode Q5103 is present
  4. 250% of Medicare lab
  5. 123% of Medicare drug
  6. 250% of Medicare DME
  7. 250% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL - UPMC Medicare Profees7 base · 18 adj
UPMC Medicare
Profee · all facilities · 2025-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. flat $41.52 — when ProcedureCode Q5121 is present
  3. flat $54.47 — when ProcedureCode Q5103 is present
  4. 105% of Medicare lab
  5. 100% of Medicare drug
  6. 105% of Medicare DME
  7. 105% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL-Aetna Medicare Profees3 base · 18 adj
Aetna-Medicare-PA
Profee · RGAL · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 100% of the Carveouts fee schedule
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL-Aetna Profees4 base · 18 adj
Aetna, Aetna-HMO, Aetna-PPO
Profee · RGAL · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 100% of the Carveouts fee schedule
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. multiple-procedure reduction (contract rules) — base codes 2, 3; pays 100/50%
  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
RGAL-CapitalBlue Facility Profees4 base · 18 adj
Capital Blue
Profee · RGAL, ASC, Hospital · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 100% of the Carveouts fee schedule
  4. 100% of the Facility-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL-CapitalBlue Profees4 base · 18 adj
Capital Blue
Profee · RGAL, Clinic · 2024-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 100% of the Carveouts fee schedule
  4. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL-Cigna Profees4 base · 18 adj
Cigna
Profee · RGAL · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 100% of the Carveouts fee schedule
  4. 123% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL-Devoted Health Profees5 base · 18 adj
Devoted Health
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs 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-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL-Independence Commercial Profees7 base · 18 adj
Independence Commercial, Independence Medicare
Profee · RGAL, ASC, Clinic, Hospital · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 100% of the Independence-Facility-Profee-Fees fee schedule — when PlaceOfService 21 is present
  4. 100% of the Independence-Facility-Profee-Fees fee schedule — when PlaceOfService 22 is present
  5. 100% of the Independence-Facility-Profee-Fees fee schedule — when PlaceOfService 23 is present
  6. 100% of the Independence-Facility-Profee-Fees fee schedule — when PlaceOfService 24 is present
  7. 100% of the Independence-Clinic-Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
RGAL-UHC Commercial Profees16 base · 19 adj
UHC Commercial
Profee · RGAL · 2023-10-01 → 2999-12-31
Base terms — first match wins
  1. 100% of Medicare anesthesia
  2. 100% of the Fixed-Fee-Drugs fee schedule
  3. 100% of the Carveouts fee schedule
  4. computed expression (operands follow)
  5. 100% of the 2020-Medicare-Multiplier fee schedule
  6. Multiply 100% of Medicare drug (rates as of 2020-01-01)
  7. computed expression (operands follow)
  8. 100% of the 2020-Medicare-Multiplier fee schedule
  9. Multiply 100% of Medicare lab (rates as of 2020-01-01)
  10. computed expression (operands follow)
  11. 100% of the 2020-Medicare-Multiplier fee schedule
  12. Multiply 100% of Medicare DME (rates as of 2020-01-01)
  13. computed expression (operands follow)
  14. 100% of the 2020-Medicare-Multiplier fee schedule
  15. Multiply 100% of Medicare RVU (rates as of 2020-01-01)
  16. 40% of billed charges
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
Tricare/Champus4 base · 18 adj
Tricare/Champus
Profee · all facilities · 2023-01-01 → 2999-12-31
Base terms — first match wins
  1. 90% of Medicare lab
  2. 90% of Medicare drug
  3. 90% of Medicare DME
  4. 90% of Medicare RVU
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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 (2)

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

Independence-Commercial-Facility-Profees · no contract map4 base · 18 adj
no contract map — cannot be resolved
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. computed expression (operands follow)
  3. 100% of the Facility-Profee-Fees fee schedule
  4. Multiply 100% of the Independence-Multipliers fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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
New Model · contract map selects nothing3 base · 18 adj
— no insurance selected —
— no bill type selected — · — nothing selected — · 2026-05-20 → 2999-12-31
Base terms — first match wins
  1. 100% of the Fixed-Fee-Drugs fee schedule
  2. 100% of the Carveouts fee schedule
  3. 100% of the Profee-Fees fee schedule
Adjustments — all apply, in order
  1. Medicare multiple-endoscopy reduction
  2. Medicare multiple-procedure reduction — base codes 2, 3; pays 100/50%
  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