|
PRO FEE PLEURAL DRNG, PERC,W/INS OF CATH
|
Professional
|
Both
|
$121.56
|
|
|
Service Code
|
HCPCS 32556 AQ
|
| Hospital Charge Code |
732556
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$85.09 |
| Max. Negotiated Rate |
$121.56 |
| Rate for Payer: Aetna Commercial |
$115.48
|
| Rate for Payer: Aetna Medicare |
$109.40
|
| Rate for Payer: BCBS MT CHIP |
$109.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$115.48
|
| Rate for Payer: BCBS MT HealthLink |
$109.40
|
| Rate for Payer: BCBS MT Medicare |
$109.40
|
| Rate for Payer: BCBS MT POS |
$115.48
|
| Rate for Payer: BCBS MT Traditional |
$121.56
|
| Rate for Payer: Cash Price |
$109.40
|
| Rate for Payer: Cigna Commercial |
$115.48
|
| Rate for Payer: Cigna Medicare |
$109.40
|
| Rate for Payer: Medicaid All Medicaid |
$111.84
|
| Rate for Payer: Medicare All Medicare |
$85.09
|
| Rate for Payer: Monida Allegiance |
$115.48
|
| Rate for Payer: Monida First Choice Health |
$117.91
|
| Rate for Payer: Monida Montana Health Co-op |
$115.48
|
| Rate for Payer: Monida PacificSource |
$115.48
|
|
|
PRO FEE PVB THORACIC 1ST LEVEL
|
Professional
|
Both
|
$525.00
|
|
|
Service Code
|
HCPCS 64461
|
| Hospital Charge Code |
764461
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$367.50 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Aetna Commercial |
$498.75
|
| Rate for Payer: Aetna Medicare |
$472.50
|
| Rate for Payer: BCBS MT CHIP |
$472.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$498.75
|
| Rate for Payer: BCBS MT HealthLink |
$472.50
|
| Rate for Payer: BCBS MT Medicare |
$472.50
|
| Rate for Payer: BCBS MT POS |
$498.75
|
| Rate for Payer: BCBS MT Traditional |
$525.00
|
| Rate for Payer: Cash Price |
$472.50
|
| Rate for Payer: Cigna Commercial |
$498.75
|
| Rate for Payer: Cigna Medicare |
$472.50
|
| Rate for Payer: Medicaid All Medicaid |
$483.00
|
| Rate for Payer: Medicare All Medicare |
$367.50
|
| Rate for Payer: Monida Allegiance |
$498.75
|
| Rate for Payer: Monida First Choice Health |
$509.25
|
| Rate for Payer: Monida Montana Health Co-op |
$498.75
|
| Rate for Payer: Monida PacificSource |
$498.75
|
|
|
PRO FEE PVB THORACIC ADD ON LEVEL
|
Professional
|
Both
|
$276.00
|
|
|
Service Code
|
HCPCS 64462
|
| Hospital Charge Code |
764462
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$193.20 |
| Max. Negotiated Rate |
$276.00 |
| Rate for Payer: Aetna Commercial |
$262.20
|
| Rate for Payer: Aetna Medicare |
$248.40
|
| Rate for Payer: BCBS MT CHIP |
$248.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$262.20
|
| Rate for Payer: BCBS MT HealthLink |
$248.40
|
| Rate for Payer: BCBS MT Medicare |
$248.40
|
| Rate for Payer: BCBS MT POS |
$262.20
|
| Rate for Payer: BCBS MT Traditional |
$276.00
|
| Rate for Payer: Cash Price |
$248.40
|
| Rate for Payer: Cigna Commercial |
$262.20
|
| Rate for Payer: Cigna Medicare |
$248.40
|
| Rate for Payer: Medicaid All Medicaid |
$253.92
|
| Rate for Payer: Medicare All Medicare |
$193.20
|
| Rate for Payer: Monida Allegiance |
$262.20
|
| Rate for Payer: Monida First Choice Health |
$267.72
|
| Rate for Payer: Monida Montana Health Co-op |
$262.20
|
| Rate for Payer: Monida PacificSource |
$262.20
|
|
|
PRO FEE REDUCTION DISTAL FRACTURE RAD
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 25505
|
| Hospital Charge Code |
782505
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$190.00
|
| Rate for Payer: Aetna Medicare |
$180.00
|
| Rate for Payer: BCBS MT CHIP |
$180.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$190.00
|
| Rate for Payer: BCBS MT HealthLink |
$180.00
|
| Rate for Payer: BCBS MT Medicare |
$180.00
|
| Rate for Payer: BCBS MT POS |
$190.00
|
| Rate for Payer: BCBS MT Traditional |
$200.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$190.00
|
| Rate for Payer: Cigna Medicare |
$180.00
|
| Rate for Payer: Medicaid All Medicaid |
$184.00
|
| Rate for Payer: Medicare All Medicare |
$140.00
|
| Rate for Payer: Monida Allegiance |
$190.00
|
| Rate for Payer: Monida First Choice Health |
$194.00
|
| Rate for Payer: Monida Montana Health Co-op |
$190.00
|
| Rate for Payer: Monida PacificSource |
$190.00
|
|
|
PRO FEE REPAIR F/E/E/N/LNTERM 2.6-5.0CM
|
Professional
|
Both
|
$210.00
|
|
|
Service Code
|
HCPCS 12052 AQ
|
| Hospital Charge Code |
712052
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna Commercial |
$199.50
|
| Rate for Payer: Aetna Medicare |
$189.00
|
| Rate for Payer: BCBS MT CHIP |
$189.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$199.50
|
| Rate for Payer: BCBS MT HealthLink |
$189.00
|
| Rate for Payer: BCBS MT Medicare |
$189.00
|
| Rate for Payer: BCBS MT POS |
$199.50
|
| Rate for Payer: BCBS MT Traditional |
$210.00
|
| Rate for Payer: Cash Price |
$189.00
|
| Rate for Payer: Cigna Commercial |
$199.50
|
| Rate for Payer: Cigna Medicare |
$189.00
|
| Rate for Payer: Medicaid All Medicaid |
$193.20
|
| Rate for Payer: Medicare All Medicare |
$147.00
|
| Rate for Payer: Monida Allegiance |
$199.50
|
| Rate for Payer: Monida First Choice Health |
$203.70
|
| Rate for Payer: Monida Montana Health Co-op |
$199.50
|
| Rate for Payer: Monida PacificSource |
$199.50
|
|
|
PRO FEE REPAIR INT =< 2.5CM
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS 12041 AQ
|
| Hospital Charge Code |
712041
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$73.50 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna Commercial |
$99.75
|
| Rate for Payer: Aetna Medicare |
$94.50
|
| Rate for Payer: BCBS MT CHIP |
$94.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$99.75
|
| Rate for Payer: BCBS MT HealthLink |
$94.50
|
| Rate for Payer: BCBS MT Medicare |
$94.50
|
| Rate for Payer: BCBS MT POS |
$99.75
|
| Rate for Payer: BCBS MT Traditional |
$105.00
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cigna Commercial |
$99.75
|
| Rate for Payer: Cigna Medicare |
$94.50
|
| Rate for Payer: Medicaid All Medicaid |
$96.60
|
| Rate for Payer: Medicare All Medicare |
$73.50
|
| Rate for Payer: Monida Allegiance |
$99.75
|
| Rate for Payer: Monida First Choice Health |
$101.85
|
| Rate for Payer: Monida Montana Health Co-op |
$99.75
|
| Rate for Payer: Monida PacificSource |
$99.75
|
|
|
PRO FEE REPAIR INTF/E/E/N/L 12.6-20.0CM
|
Professional
|
Both
|
$331.00
|
|
|
Service Code
|
HCPCS 12055 AQ
|
| Hospital Charge Code |
712055
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$231.70 |
| Max. Negotiated Rate |
$331.00 |
| Rate for Payer: Aetna Commercial |
$314.45
|
| Rate for Payer: Aetna Medicare |
$297.90
|
| Rate for Payer: BCBS MT CHIP |
$297.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$314.45
|
| Rate for Payer: BCBS MT HealthLink |
$297.90
|
| Rate for Payer: BCBS MT Medicare |
$297.90
|
| Rate for Payer: BCBS MT POS |
$314.45
|
| Rate for Payer: BCBS MT Traditional |
$331.00
|
| Rate for Payer: Cash Price |
$297.90
|
| Rate for Payer: Cigna Commercial |
$314.45
|
| Rate for Payer: Cigna Medicare |
$297.90
|
| Rate for Payer: Medicaid All Medicaid |
$304.52
|
| Rate for Payer: Medicare All Medicare |
$231.70
|
| Rate for Payer: Monida Allegiance |
$314.45
|
| Rate for Payer: Monida First Choice Health |
$321.07
|
| Rate for Payer: Monida Montana Health Co-op |
$314.45
|
| Rate for Payer: Monida PacificSource |
$314.45
|
|
|
PRO FEE REPAIR INT F/E/E/N/L 5.1-7.5CM
|
Professional
|
Both
|
$232.00
|
|
|
Service Code
|
HCPCS 12053 AQ
|
| Hospital Charge Code |
712053
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$162.40 |
| Max. Negotiated Rate |
$232.00 |
| Rate for Payer: Aetna Commercial |
$220.40
|
| Rate for Payer: Aetna Medicare |
$208.80
|
| Rate for Payer: BCBS MT CHIP |
$208.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$220.40
|
| Rate for Payer: BCBS MT HealthLink |
$208.80
|
| Rate for Payer: BCBS MT Medicare |
$208.80
|
| Rate for Payer: BCBS MT POS |
$220.40
|
| Rate for Payer: BCBS MT Traditional |
$232.00
|
| Rate for Payer: Cash Price |
$208.80
|
| Rate for Payer: Cigna Commercial |
$220.40
|
| Rate for Payer: Cigna Medicare |
$208.80
|
| Rate for Payer: Medicaid All Medicaid |
$213.44
|
| Rate for Payer: Medicare All Medicare |
$162.40
|
| Rate for Payer: Monida Allegiance |
$220.40
|
| Rate for Payer: Monida First Choice Health |
$225.04
|
| Rate for Payer: Monida Montana Health Co-op |
$220.40
|
| Rate for Payer: Monida PacificSource |
$220.40
|
|
|
PRO FEE REPAIR INT F/E/E/N/L 7.6-12.5CM
|
Professional
|
Both
|
$233.00
|
|
|
Service Code
|
HCPCS 12054 AQ
|
| Hospital Charge Code |
712054
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$163.10 |
| Max. Negotiated Rate |
$233.00 |
| Rate for Payer: Aetna Commercial |
$221.35
|
| Rate for Payer: Aetna Medicare |
$209.70
|
| Rate for Payer: BCBS MT CHIP |
$209.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$221.35
|
| Rate for Payer: BCBS MT HealthLink |
$209.70
|
| Rate for Payer: BCBS MT Medicare |
$209.70
|
| Rate for Payer: BCBS MT POS |
$221.35
|
| Rate for Payer: BCBS MT Traditional |
$233.00
|
| Rate for Payer: Cash Price |
$209.70
|
| Rate for Payer: Cigna Commercial |
$221.35
|
| Rate for Payer: Cigna Medicare |
$209.70
|
| Rate for Payer: Medicaid All Medicaid |
$214.36
|
| Rate for Payer: Medicare All Medicare |
$163.10
|
| Rate for Payer: Monida Allegiance |
$221.35
|
| Rate for Payer: Monida First Choice Health |
$226.01
|
| Rate for Payer: Monida Montana Health Co-op |
$221.35
|
| Rate for Payer: Monida PacificSource |
$221.35
|
|
|
PRO FEE REPAIR INT N/H/F/EXTG 7.6-12.5CM
|
Professional
|
Both
|
$231.00
|
|
|
Service Code
|
HCPCS 12044 AQ
|
| Hospital Charge Code |
712044
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$161.70 |
| Max. Negotiated Rate |
$231.00 |
| Rate for Payer: Aetna Commercial |
$219.45
|
| Rate for Payer: Aetna Medicare |
$207.90
|
| Rate for Payer: BCBS MT CHIP |
$207.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$219.45
|
| Rate for Payer: BCBS MT HealthLink |
$207.90
|
| Rate for Payer: BCBS MT Medicare |
$207.90
|
| Rate for Payer: BCBS MT POS |
$219.45
|
| Rate for Payer: BCBS MT Traditional |
$231.00
|
| Rate for Payer: Cash Price |
$207.90
|
| Rate for Payer: Cigna Commercial |
$219.45
|
| Rate for Payer: Cigna Medicare |
$207.90
|
| Rate for Payer: Medicaid All Medicaid |
$212.52
|
| Rate for Payer: Medicare All Medicare |
$161.70
|
| Rate for Payer: Monida Allegiance |
$219.45
|
| Rate for Payer: Monida First Choice Health |
$224.07
|
| Rate for Payer: Monida Montana Health Co-op |
$219.45
|
| Rate for Payer: Monida PacificSource |
$219.45
|
|
|
PRO FEE REPAIR INT N/H/F/G 2.5-7.5CM
|
Professional
|
Both
|
$205.00
|
|
|
Service Code
|
HCPCS 12042 AQ
|
| Hospital Charge Code |
712042
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$143.50 |
| Max. Negotiated Rate |
$205.00 |
| Rate for Payer: Aetna Commercial |
$194.75
|
| Rate for Payer: Aetna Medicare |
$184.50
|
| Rate for Payer: BCBS MT CHIP |
$184.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$194.75
|
| Rate for Payer: BCBS MT HealthLink |
$184.50
|
| Rate for Payer: BCBS MT Medicare |
$184.50
|
| Rate for Payer: BCBS MT POS |
$194.75
|
| Rate for Payer: BCBS MT Traditional |
$205.00
|
| Rate for Payer: Cash Price |
$184.50
|
| Rate for Payer: Cigna Commercial |
$194.75
|
| Rate for Payer: Cigna Medicare |
$184.50
|
| Rate for Payer: Medicaid All Medicaid |
$188.60
|
| Rate for Payer: Medicare All Medicare |
$143.50
|
| Rate for Payer: Monida Allegiance |
$194.75
|
| Rate for Payer: Monida First Choice Health |
$198.85
|
| Rate for Payer: Monida Montana Health Co-op |
$194.75
|
| Rate for Payer: Monida PacificSource |
$194.75
|
|
|
PRO FEE REPAIR INT S/A/T/E 12.6-20.CM
|
Professional
|
Both
|
$257.00
|
|
|
Service Code
|
HCPCS 12035 AQ
|
| Hospital Charge Code |
712035
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$179.90 |
| Max. Negotiated Rate |
$257.00 |
| Rate for Payer: Aetna Commercial |
$244.15
|
| Rate for Payer: Aetna Medicare |
$231.30
|
| Rate for Payer: BCBS MT CHIP |
$231.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$244.15
|
| Rate for Payer: BCBS MT HealthLink |
$231.30
|
| Rate for Payer: BCBS MT Medicare |
$231.30
|
| Rate for Payer: BCBS MT POS |
$244.15
|
| Rate for Payer: BCBS MT Traditional |
$257.00
|
| Rate for Payer: Cash Price |
$231.30
|
| Rate for Payer: Cigna Commercial |
$244.15
|
| Rate for Payer: Cigna Medicare |
$231.30
|
| Rate for Payer: Medicaid All Medicaid |
$236.44
|
| Rate for Payer: Medicare All Medicare |
$179.90
|
| Rate for Payer: Monida Allegiance |
$244.15
|
| Rate for Payer: Monida First Choice Health |
$249.29
|
| Rate for Payer: Monida Montana Health Co-op |
$244.15
|
| Rate for Payer: Monida PacificSource |
$244.15
|
|
|
PRO FEE REPAIR INT S/A/T/E<2.5CM
|
Professional
|
Both
|
$147.00
|
|
|
Service Code
|
HCPCS 12031 AQ
|
| Hospital Charge Code |
712031
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Medicare |
$132.30
|
| Rate for Payer: BCBS MT CHIP |
$132.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$139.65
|
| Rate for Payer: BCBS MT HealthLink |
$132.30
|
| Rate for Payer: BCBS MT Medicare |
$132.30
|
| Rate for Payer: BCBS MT POS |
$139.65
|
| Rate for Payer: BCBS MT Traditional |
$147.00
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cigna Medicare |
$132.30
|
| Rate for Payer: Medicaid All Medicaid |
$135.24
|
| Rate for Payer: Medicare All Medicare |
$102.90
|
| Rate for Payer: Monida Allegiance |
$139.65
|
| Rate for Payer: Monida First Choice Health |
$142.59
|
| Rate for Payer: Monida Montana Health Co-op |
$139.65
|
| Rate for Payer: Monida PacificSource |
$139.65
|
|
|
PRO FEE REPAIR INT S/A/T/E 2.6-7.5CM
|
Professional
|
Both
|
$185.00
|
|
|
Service Code
|
HCPCS 12032 AQ
|
| Hospital Charge Code |
712032
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$129.50 |
| Max. Negotiated Rate |
$185.00 |
| Rate for Payer: Aetna Commercial |
$175.75
|
| Rate for Payer: Aetna Medicare |
$166.50
|
| Rate for Payer: BCBS MT CHIP |
$166.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$175.75
|
| Rate for Payer: BCBS MT HealthLink |
$166.50
|
| Rate for Payer: BCBS MT Medicare |
$166.50
|
| Rate for Payer: BCBS MT POS |
$175.75
|
| Rate for Payer: BCBS MT Traditional |
$185.00
|
| Rate for Payer: Cash Price |
$166.50
|
| Rate for Payer: Cigna Commercial |
$175.75
|
| Rate for Payer: Cigna Medicare |
$166.50
|
| Rate for Payer: Medicaid All Medicaid |
$170.20
|
| Rate for Payer: Medicare All Medicare |
$129.50
|
| Rate for Payer: Monida Allegiance |
$175.75
|
| Rate for Payer: Monida First Choice Health |
$179.45
|
| Rate for Payer: Monida Montana Health Co-op |
$175.75
|
| Rate for Payer: Monida PacificSource |
$175.75
|
|
|
PRO FEE REPAIR INT S/A/T/E 7.6-12.5CM
|
Professional
|
Both
|
$219.00
|
|
|
Service Code
|
HCPCS 12034 AQ
|
| Hospital Charge Code |
712034
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$153.30 |
| Max. Negotiated Rate |
$219.00 |
| Rate for Payer: Aetna Commercial |
$208.05
|
| Rate for Payer: Aetna Medicare |
$197.10
|
| Rate for Payer: BCBS MT CHIP |
$197.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$208.05
|
| Rate for Payer: BCBS MT HealthLink |
$197.10
|
| Rate for Payer: BCBS MT Medicare |
$197.10
|
| Rate for Payer: BCBS MT POS |
$208.05
|
| Rate for Payer: BCBS MT Traditional |
$219.00
|
| Rate for Payer: Cash Price |
$197.10
|
| Rate for Payer: Cigna Commercial |
$208.05
|
| Rate for Payer: Cigna Medicare |
$197.10
|
| Rate for Payer: Medicaid All Medicaid |
$201.48
|
| Rate for Payer: Medicare All Medicare |
$153.30
|
| Rate for Payer: Monida Allegiance |
$208.05
|
| Rate for Payer: Monida First Choice Health |
$212.43
|
| Rate for Payer: Monida Montana Health Co-op |
$208.05
|
| Rate for Payer: Monida PacificSource |
$208.05
|
|
|
PRO FEE REPAIR SIMPLE FACE...7.6-12.5
|
Professional
|
Both
|
$147.00
|
|
|
Service Code
|
HCPCS 12015 AQ
|
| Hospital Charge Code |
712015
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$102.90 |
| Max. Negotiated Rate |
$147.00 |
| Rate for Payer: Aetna Commercial |
$139.65
|
| Rate for Payer: Aetna Medicare |
$132.30
|
| Rate for Payer: BCBS MT CHIP |
$132.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$139.65
|
| Rate for Payer: BCBS MT HealthLink |
$132.30
|
| Rate for Payer: BCBS MT Medicare |
$132.30
|
| Rate for Payer: BCBS MT POS |
$139.65
|
| Rate for Payer: BCBS MT Traditional |
$147.00
|
| Rate for Payer: Cash Price |
$132.30
|
| Rate for Payer: Cigna Commercial |
$139.65
|
| Rate for Payer: Cigna Medicare |
$132.30
|
| Rate for Payer: Medicaid All Medicaid |
$135.24
|
| Rate for Payer: Medicare All Medicare |
$102.90
|
| Rate for Payer: Monida Allegiance |
$139.65
|
| Rate for Payer: Monida First Choice Health |
$142.59
|
| Rate for Payer: Monida Montana Health Co-op |
$139.65
|
| Rate for Payer: Monida PacificSource |
$139.65
|
|
|
PRO FEE REPAIR SIMPLE S/N/A/G/T/E12.6-20
|
Professional
|
Both
|
$145.00
|
|
|
Service Code
|
HCPCS 12005 AQ
|
| Hospital Charge Code |
712005
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$101.50 |
| Max. Negotiated Rate |
$145.00 |
| Rate for Payer: Aetna Commercial |
$137.75
|
| Rate for Payer: Aetna Medicare |
$130.50
|
| Rate for Payer: BCBS MT CHIP |
$130.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$137.75
|
| Rate for Payer: BCBS MT HealthLink |
$130.50
|
| Rate for Payer: BCBS MT Medicare |
$130.50
|
| Rate for Payer: BCBS MT POS |
$137.75
|
| Rate for Payer: BCBS MT Traditional |
$145.00
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cigna Commercial |
$137.75
|
| Rate for Payer: Cigna Medicare |
$130.50
|
| Rate for Payer: Medicaid All Medicaid |
$133.40
|
| Rate for Payer: Medicare All Medicare |
$101.50
|
| Rate for Payer: Monida Allegiance |
$137.75
|
| Rate for Payer: Monida First Choice Health |
$140.65
|
| Rate for Payer: Monida Montana Health Co-op |
$137.75
|
| Rate for Payer: Monida PacificSource |
$137.75
|
|
|
PRO FEE REPAIR S/N/AX/G/T >30CM
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
HCPCS 12007 AQ
|
| Hospital Charge Code |
782007
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$149.10 |
| Max. Negotiated Rate |
$213.00 |
| Rate for Payer: Aetna Commercial |
$202.35
|
| Rate for Payer: Aetna Medicare |
$191.70
|
| Rate for Payer: BCBS MT CHIP |
$191.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$202.35
|
| Rate for Payer: BCBS MT HealthLink |
$191.70
|
| Rate for Payer: BCBS MT Medicare |
$191.70
|
| Rate for Payer: BCBS MT POS |
$202.35
|
| Rate for Payer: BCBS MT Traditional |
$213.00
|
| Rate for Payer: Cash Price |
$191.70
|
| Rate for Payer: Cigna Commercial |
$202.35
|
| Rate for Payer: Cigna Medicare |
$191.70
|
| Rate for Payer: Medicaid All Medicaid |
$195.96
|
| Rate for Payer: Medicare All Medicare |
$149.10
|
| Rate for Payer: Monida Allegiance |
$202.35
|
| Rate for Payer: Monida First Choice Health |
$206.61
|
| Rate for Payer: Monida Montana Health Co-op |
$202.35
|
| Rate for Payer: Monida PacificSource |
$202.35
|
|
|
PRO FEE REPAIR WOUND COMPLEX 1.1-2.5CM
|
Professional
|
Both
|
$274.00
|
|
|
Service Code
|
HCPCS 13131 AQ
|
| Hospital Charge Code |
713131
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$191.80 |
| Max. Negotiated Rate |
$274.00 |
| Rate for Payer: Aetna Commercial |
$260.30
|
| Rate for Payer: Aetna Medicare |
$246.60
|
| Rate for Payer: BCBS MT CHIP |
$246.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$260.30
|
| Rate for Payer: BCBS MT HealthLink |
$246.60
|
| Rate for Payer: BCBS MT Medicare |
$246.60
|
| Rate for Payer: BCBS MT POS |
$260.30
|
| Rate for Payer: BCBS MT Traditional |
$274.00
|
| Rate for Payer: Cash Price |
$246.60
|
| Rate for Payer: Cigna Commercial |
$260.30
|
| Rate for Payer: Cigna Medicare |
$246.60
|
| Rate for Payer: Medicaid All Medicaid |
$252.08
|
| Rate for Payer: Medicare All Medicare |
$191.80
|
| Rate for Payer: Monida Allegiance |
$260.30
|
| Rate for Payer: Monida First Choice Health |
$265.78
|
| Rate for Payer: Monida Montana Health Co-op |
$260.30
|
| Rate for Payer: Monida PacificSource |
$260.30
|
|
|
PRO FEE REPAIR WOUND INT=< 2.5
|
Professional
|
Both
|
$171.00
|
|
|
Service Code
|
HCPCS 12051 AQ
|
| Hospital Charge Code |
712051
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$119.70 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna Commercial |
$162.45
|
| Rate for Payer: Aetna Medicare |
$153.90
|
| Rate for Payer: BCBS MT CHIP |
$153.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$162.45
|
| Rate for Payer: BCBS MT HealthLink |
$153.90
|
| Rate for Payer: BCBS MT Medicare |
$153.90
|
| Rate for Payer: BCBS MT POS |
$162.45
|
| Rate for Payer: BCBS MT Traditional |
$171.00
|
| Rate for Payer: Cash Price |
$153.90
|
| Rate for Payer: Cigna Commercial |
$162.45
|
| Rate for Payer: Cigna Medicare |
$153.90
|
| Rate for Payer: Medicaid All Medicaid |
$157.32
|
| Rate for Payer: Medicare All Medicare |
$119.70
|
| Rate for Payer: Monida Allegiance |
$162.45
|
| Rate for Payer: Monida First Choice Health |
$165.87
|
| Rate for Payer: Monida Montana Health Co-op |
$162.45
|
| Rate for Payer: Monida PacificSource |
$162.45
|
|
|
PRO FEE REPAIR WOUND SIMPLE 2.5CM/LESS
|
Professional
|
Both
|
$79.00
|
|
|
Service Code
|
HCPCS 12011 AQ
|
| Hospital Charge Code |
712011
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$55.30 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: Aetna Commercial |
$75.05
|
| Rate for Payer: Aetna Medicare |
$71.10
|
| Rate for Payer: BCBS MT CHIP |
$71.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$75.05
|
| Rate for Payer: BCBS MT HealthLink |
$71.10
|
| Rate for Payer: BCBS MT Medicare |
$71.10
|
| Rate for Payer: BCBS MT POS |
$75.05
|
| Rate for Payer: BCBS MT Traditional |
$79.00
|
| Rate for Payer: Cash Price |
$71.10
|
| Rate for Payer: Cigna Commercial |
$75.05
|
| Rate for Payer: Cigna Medicare |
$71.10
|
| Rate for Payer: Medicaid All Medicaid |
$72.68
|
| Rate for Payer: Medicare All Medicare |
$55.30
|
| Rate for Payer: Monida Allegiance |
$75.05
|
| Rate for Payer: Monida First Choice Health |
$76.63
|
| Rate for Payer: Monida Montana Health Co-op |
$75.05
|
| Rate for Payer: Monida PacificSource |
$75.05
|
|
|
PRO FEE REPAIR WOUND SIMPLE 2.6-5.0CM
|
Professional
|
Both
|
$90.00
|
|
|
Service Code
|
HCPCS 12013 AQ
|
| Hospital Charge Code |
712013
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$63.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna Commercial |
$85.50
|
| Rate for Payer: Aetna Medicare |
$81.00
|
| Rate for Payer: BCBS MT CHIP |
$81.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$85.50
|
| Rate for Payer: BCBS MT HealthLink |
$81.00
|
| Rate for Payer: BCBS MT Medicare |
$81.00
|
| Rate for Payer: BCBS MT POS |
$85.50
|
| Rate for Payer: BCBS MT Traditional |
$90.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$85.50
|
| Rate for Payer: Cigna Medicare |
$81.00
|
| Rate for Payer: Medicaid All Medicaid |
$82.80
|
| Rate for Payer: Medicare All Medicare |
$63.00
|
| Rate for Payer: Monida Allegiance |
$85.50
|
| Rate for Payer: Monida First Choice Health |
$87.30
|
| Rate for Payer: Monida Montana Health Co-op |
$85.50
|
| Rate for Payer: Monida PacificSource |
$85.50
|
|
|
PRO FEE REPAIR WOUND SIMPLE 5.1-7.5CM
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS 12014 AQ
|
| Hospital Charge Code |
712014
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$81.20 |
| Max. Negotiated Rate |
$116.00 |
| Rate for Payer: Aetna Commercial |
$110.20
|
| Rate for Payer: Aetna Medicare |
$104.40
|
| Rate for Payer: BCBS MT CHIP |
$104.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$110.20
|
| Rate for Payer: BCBS MT HealthLink |
$104.40
|
| Rate for Payer: BCBS MT Medicare |
$104.40
|
| Rate for Payer: BCBS MT POS |
$110.20
|
| Rate for Payer: BCBS MT Traditional |
$116.00
|
| Rate for Payer: Cash Price |
$104.40
|
| Rate for Payer: Cigna Commercial |
$110.20
|
| Rate for Payer: Cigna Medicare |
$104.40
|
| Rate for Payer: Medicaid All Medicaid |
$106.72
|
| Rate for Payer: Medicare All Medicare |
$81.20
|
| Rate for Payer: Monida Allegiance |
$110.20
|
| Rate for Payer: Monida First Choice Health |
$112.52
|
| Rate for Payer: Monida Montana Health Co-op |
$110.20
|
| Rate for Payer: Monida PacificSource |
$110.20
|
|
|
PROFEE RF ABLTJ NRV NRVTG SI JT W/I
|
Professional
|
Both
|
$520.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
7664625
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$520.00 |
| Rate for Payer: Aetna Commercial |
$494.00
|
| Rate for Payer: Aetna Medicare |
$468.00
|
| Rate for Payer: BCBS MT CHIP |
$468.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$494.00
|
| Rate for Payer: BCBS MT HealthLink |
$468.00
|
| Rate for Payer: BCBS MT Medicare |
$468.00
|
| Rate for Payer: BCBS MT POS |
$494.00
|
| Rate for Payer: BCBS MT Traditional |
$520.00
|
| Rate for Payer: Cash Price |
$468.00
|
| Rate for Payer: Cigna Commercial |
$494.00
|
| Rate for Payer: Cigna Medicare |
$468.00
|
| Rate for Payer: Medicaid All Medicaid |
$478.40
|
| Rate for Payer: Medicare All Medicare |
$364.00
|
| Rate for Payer: Monida Allegiance |
$494.00
|
| Rate for Payer: Monida First Choice Health |
$504.40
|
| Rate for Payer: Monida Montana Health Co-op |
$494.00
|
| Rate for Payer: Monida PacificSource |
$494.00
|
|
|
PRO FEE SMALL JOINT INJ W/O US 20600
|
Professional
|
Both
|
$226.00
|
|
|
Service Code
|
HCPCS 20600
|
| Hospital Charge Code |
720600
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$158.20 |
| Max. Negotiated Rate |
$226.00 |
| Rate for Payer: Aetna Commercial |
$214.70
|
| Rate for Payer: Aetna Medicare |
$203.40
|
| Rate for Payer: BCBS MT CHIP |
$203.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$214.70
|
| Rate for Payer: BCBS MT HealthLink |
$203.40
|
| Rate for Payer: BCBS MT Medicare |
$203.40
|
| Rate for Payer: BCBS MT POS |
$214.70
|
| Rate for Payer: BCBS MT Traditional |
$226.00
|
| Rate for Payer: Cash Price |
$203.40
|
| Rate for Payer: Cigna Commercial |
$214.70
|
| Rate for Payer: Cigna Medicare |
$203.40
|
| Rate for Payer: Medicaid All Medicaid |
$207.92
|
| Rate for Payer: Medicare All Medicare |
$158.20
|
| Rate for Payer: Monida Allegiance |
$214.70
|
| Rate for Payer: Monida First Choice Health |
$219.22
|
| Rate for Payer: Monida Montana Health Co-op |
$214.70
|
| Rate for Payer: Monida PacificSource |
$214.70
|
|
