|
PRO FEE REPAIR F/E/E/N/LNTERM 2.6-5.0CM
|
Professional
|
Both
|
$382.00
|
|
|
Service Code
|
HCPCS 12052 AQ
|
| Hospital Charge Code |
712052
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$267.40 |
| Max. Negotiated Rate |
$382.00 |
| Rate for Payer: Aetna Commercial |
$362.90
|
| Rate for Payer: Aetna Medicare |
$343.80
|
| Rate for Payer: BCBS MT CHIP |
$343.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$362.90
|
| Rate for Payer: BCBS MT HealthLink |
$343.80
|
| Rate for Payer: BCBS MT Medicare |
$343.80
|
| Rate for Payer: BCBS MT POS |
$362.90
|
| Rate for Payer: BCBS MT Traditional |
$382.00
|
| Rate for Payer: Cash Price |
$343.80
|
| Rate for Payer: Cigna Commercial |
$362.90
|
| Rate for Payer: Cigna Medicare |
$343.80
|
| Rate for Payer: Medicaid All Medicaid |
$351.44
|
| Rate for Payer: Medicare All Medicare |
$267.40
|
| Rate for Payer: Monida Allegiance |
$362.90
|
| Rate for Payer: Monida First Choice Health |
$370.54
|
| Rate for Payer: Monida Montana Health Co-op |
$362.90
|
| Rate for Payer: Monida PacificSource |
$362.90
|
|
|
PRO FEE REPAIR INT =< 2.5CM
|
Professional
|
Both
|
$279.00
|
|
|
Service Code
|
HCPCS 12041 AQ
|
| Hospital Charge Code |
712041
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$195.30 |
| Max. Negotiated Rate |
$279.00 |
| Rate for Payer: Aetna Commercial |
$265.05
|
| Rate for Payer: Aetna Medicare |
$251.10
|
| Rate for Payer: BCBS MT CHIP |
$251.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$265.05
|
| Rate for Payer: BCBS MT HealthLink |
$251.10
|
| Rate for Payer: BCBS MT Medicare |
$251.10
|
| Rate for Payer: BCBS MT POS |
$265.05
|
| Rate for Payer: BCBS MT Traditional |
$279.00
|
| Rate for Payer: Cash Price |
$251.10
|
| Rate for Payer: Cigna Commercial |
$265.05
|
| Rate for Payer: Cigna Medicare |
$251.10
|
| Rate for Payer: Medicaid All Medicaid |
$256.68
|
| Rate for Payer: Medicare All Medicare |
$195.30
|
| Rate for Payer: Monida Allegiance |
$265.05
|
| Rate for Payer: Monida First Choice Health |
$270.63
|
| Rate for Payer: Monida Montana Health Co-op |
$265.05
|
| Rate for Payer: Monida PacificSource |
$265.05
|
|
|
PRO FEE REPAIR INTF/E/E/N/L 12.6-20.0CM
|
Professional
|
Both
|
$576.00
|
|
|
Service Code
|
HCPCS 12055 AQ
|
| Hospital Charge Code |
712055
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$403.20 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$547.20
|
| Rate for Payer: Aetna Medicare |
$518.40
|
| Rate for Payer: BCBS MT CHIP |
$518.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$547.20
|
| Rate for Payer: BCBS MT HealthLink |
$518.40
|
| Rate for Payer: BCBS MT Medicare |
$518.40
|
| Rate for Payer: BCBS MT POS |
$547.20
|
| Rate for Payer: BCBS MT Traditional |
$576.00
|
| Rate for Payer: Cash Price |
$518.40
|
| Rate for Payer: Cigna Commercial |
$547.20
|
| Rate for Payer: Cigna Medicare |
$518.40
|
| Rate for Payer: Medicaid All Medicaid |
$529.92
|
| Rate for Payer: Medicare All Medicare |
$403.20
|
| Rate for Payer: Monida Allegiance |
$547.20
|
| Rate for Payer: Monida First Choice Health |
$558.72
|
| Rate for Payer: Monida Montana Health Co-op |
$547.20
|
| Rate for Payer: Monida PacificSource |
$547.20
|
|
|
PRO FEE REPAIR INT F/E/E/N/L 5.1-7.5CM
|
Professional
|
Both
|
$412.00
|
|
|
Service Code
|
HCPCS 12053 AQ
|
| Hospital Charge Code |
712053
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$288.40 |
| Max. Negotiated Rate |
$412.00 |
| Rate for Payer: Aetna Commercial |
$391.40
|
| Rate for Payer: Aetna Medicare |
$370.80
|
| Rate for Payer: BCBS MT CHIP |
$370.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$391.40
|
| Rate for Payer: BCBS MT HealthLink |
$370.80
|
| Rate for Payer: BCBS MT Medicare |
$370.80
|
| Rate for Payer: BCBS MT POS |
$391.40
|
| Rate for Payer: BCBS MT Traditional |
$412.00
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$391.40
|
| Rate for Payer: Cigna Medicare |
$370.80
|
| Rate for Payer: Medicaid All Medicaid |
$379.04
|
| Rate for Payer: Medicare All Medicare |
$288.40
|
| Rate for Payer: Monida Allegiance |
$391.40
|
| Rate for Payer: Monida First Choice Health |
$399.64
|
| Rate for Payer: Monida Montana Health Co-op |
$391.40
|
| Rate for Payer: Monida PacificSource |
$391.40
|
|
|
PRO FEE REPAIR INT F/E/E/N/L 7.6-12.5CM
|
Professional
|
Both
|
$420.00
|
|
|
Service Code
|
HCPCS 12054 AQ
|
| Hospital Charge Code |
712054
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$294.00 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$399.00
|
| Rate for Payer: Aetna Medicare |
$378.00
|
| Rate for Payer: BCBS MT CHIP |
$378.00
|
| Rate for Payer: BCBS MT Closed Plan Network |
$399.00
|
| Rate for Payer: BCBS MT HealthLink |
$378.00
|
| Rate for Payer: BCBS MT Medicare |
$378.00
|
| Rate for Payer: BCBS MT POS |
$399.00
|
| Rate for Payer: BCBS MT Traditional |
$420.00
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Cigna Commercial |
$399.00
|
| Rate for Payer: Cigna Medicare |
$378.00
|
| Rate for Payer: Medicaid All Medicaid |
$386.40
|
| Rate for Payer: Medicare All Medicare |
$294.00
|
| Rate for Payer: Monida Allegiance |
$399.00
|
| Rate for Payer: Monida First Choice Health |
$407.40
|
| Rate for Payer: Monida Montana Health Co-op |
$399.00
|
| Rate for Payer: Monida PacificSource |
$399.00
|
|
|
PRO FEE REPAIR INT N/H/F/EXTG 7.6-12.5CM
|
Professional
|
Both
|
$412.00
|
|
|
Service Code
|
HCPCS 12044 AQ
|
| Hospital Charge Code |
712044
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$288.40 |
| Max. Negotiated Rate |
$412.00 |
| Rate for Payer: Aetna Commercial |
$391.40
|
| Rate for Payer: Aetna Medicare |
$370.80
|
| Rate for Payer: BCBS MT CHIP |
$370.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$391.40
|
| Rate for Payer: BCBS MT HealthLink |
$370.80
|
| Rate for Payer: BCBS MT Medicare |
$370.80
|
| Rate for Payer: BCBS MT POS |
$391.40
|
| Rate for Payer: BCBS MT Traditional |
$412.00
|
| Rate for Payer: Cash Price |
$370.80
|
| Rate for Payer: Cigna Commercial |
$391.40
|
| Rate for Payer: Cigna Medicare |
$370.80
|
| Rate for Payer: Medicaid All Medicaid |
$379.04
|
| Rate for Payer: Medicare All Medicare |
$288.40
|
| Rate for Payer: Monida Allegiance |
$391.40
|
| Rate for Payer: Monida First Choice Health |
$399.64
|
| Rate for Payer: Monida Montana Health Co-op |
$391.40
|
| Rate for Payer: Monida PacificSource |
$391.40
|
|
|
PRO FEE REPAIR INT N/H/F/G 2.5-7.5CM
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 12042 AQ
|
| Hospital Charge Code |
712042
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Aetna Commercial |
$356.25
|
| Rate for Payer: Aetna Medicare |
$337.50
|
| Rate for Payer: BCBS MT CHIP |
$337.50
|
| Rate for Payer: BCBS MT Closed Plan Network |
$356.25
|
| Rate for Payer: BCBS MT HealthLink |
$337.50
|
| Rate for Payer: BCBS MT Medicare |
$337.50
|
| Rate for Payer: BCBS MT POS |
$356.25
|
| Rate for Payer: BCBS MT Traditional |
$375.00
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$356.25
|
| Rate for Payer: Cigna Medicare |
$337.50
|
| Rate for Payer: Medicaid All Medicaid |
$345.00
|
| Rate for Payer: Medicare All Medicare |
$262.50
|
| Rate for Payer: Monida Allegiance |
$356.25
|
| Rate for Payer: Monida First Choice Health |
$363.75
|
| Rate for Payer: Monida Montana Health Co-op |
$356.25
|
| Rate for Payer: Monida PacificSource |
$356.25
|
|
|
PRO FEE REPAIR INT S/A/T/E 12.6-20.CM
|
Professional
|
Both
|
$463.00
|
|
|
Service Code
|
HCPCS 12035 AQ
|
| Hospital Charge Code |
712035
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$324.10 |
| Max. Negotiated Rate |
$463.00 |
| Rate for Payer: Aetna Commercial |
$439.85
|
| Rate for Payer: Aetna Medicare |
$416.70
|
| Rate for Payer: BCBS MT CHIP |
$416.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$439.85
|
| Rate for Payer: BCBS MT HealthLink |
$416.70
|
| Rate for Payer: BCBS MT Medicare |
$416.70
|
| Rate for Payer: BCBS MT POS |
$439.85
|
| Rate for Payer: BCBS MT Traditional |
$463.00
|
| Rate for Payer: Cash Price |
$416.70
|
| Rate for Payer: Cigna Commercial |
$439.85
|
| Rate for Payer: Cigna Medicare |
$416.70
|
| Rate for Payer: Medicaid All Medicaid |
$425.96
|
| Rate for Payer: Medicare All Medicare |
$324.10
|
| Rate for Payer: Monida Allegiance |
$439.85
|
| Rate for Payer: Monida First Choice Health |
$449.11
|
| Rate for Payer: Monida Montana Health Co-op |
$439.85
|
| Rate for Payer: Monida PacificSource |
$439.85
|
|
|
PRO FEE REPAIR INT S/A/T/E<2.5CM
|
Professional
|
Both
|
$291.00
|
|
|
Service Code
|
HCPCS 12031 AQ
|
| Hospital Charge Code |
712031
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$203.70 |
| Max. Negotiated Rate |
$291.00 |
| Rate for Payer: Aetna Commercial |
$276.45
|
| Rate for Payer: Aetna Medicare |
$261.90
|
| Rate for Payer: BCBS MT CHIP |
$261.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$276.45
|
| Rate for Payer: BCBS MT HealthLink |
$261.90
|
| Rate for Payer: BCBS MT Medicare |
$261.90
|
| Rate for Payer: BCBS MT POS |
$276.45
|
| Rate for Payer: BCBS MT Traditional |
$291.00
|
| Rate for Payer: Cash Price |
$261.90
|
| Rate for Payer: Cigna Commercial |
$276.45
|
| Rate for Payer: Cigna Medicare |
$261.90
|
| Rate for Payer: Medicaid All Medicaid |
$267.72
|
| Rate for Payer: Medicare All Medicare |
$203.70
|
| Rate for Payer: Monida Allegiance |
$276.45
|
| Rate for Payer: Monida First Choice Health |
$282.27
|
| Rate for Payer: Monida Montana Health Co-op |
$276.45
|
| Rate for Payer: Monida PacificSource |
$276.45
|
|
|
PRO FEE REPAIR INT S/A/T/E 2.6-7.5CM
|
Professional
|
Both
|
$366.00
|
|
|
Service Code
|
HCPCS 12032 AQ
|
| Hospital Charge Code |
712032
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$256.20 |
| Max. Negotiated Rate |
$366.00 |
| Rate for Payer: Aetna Commercial |
$347.70
|
| Rate for Payer: Aetna Medicare |
$329.40
|
| Rate for Payer: BCBS MT CHIP |
$329.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$347.70
|
| Rate for Payer: BCBS MT HealthLink |
$329.40
|
| Rate for Payer: BCBS MT Medicare |
$329.40
|
| Rate for Payer: BCBS MT POS |
$347.70
|
| Rate for Payer: BCBS MT Traditional |
$366.00
|
| Rate for Payer: Cash Price |
$329.40
|
| Rate for Payer: Cigna Commercial |
$347.70
|
| Rate for Payer: Cigna Medicare |
$329.40
|
| Rate for Payer: Medicaid All Medicaid |
$336.72
|
| Rate for Payer: Medicare All Medicare |
$256.20
|
| Rate for Payer: Monida Allegiance |
$347.70
|
| Rate for Payer: Monida First Choice Health |
$355.02
|
| Rate for Payer: Monida Montana Health Co-op |
$347.70
|
| Rate for Payer: Monida PacificSource |
$347.70
|
|
|
PRO FEE REPAIR INT S/A/T/E 7.6-12.5CM
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
HCPCS 12034 AQ
|
| Hospital Charge Code |
712034
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$275.10 |
| Max. Negotiated Rate |
$393.00 |
| Rate for Payer: Aetna Commercial |
$373.35
|
| Rate for Payer: Aetna Medicare |
$353.70
|
| Rate for Payer: BCBS MT CHIP |
$353.70
|
| Rate for Payer: BCBS MT Closed Plan Network |
$373.35
|
| Rate for Payer: BCBS MT HealthLink |
$353.70
|
| Rate for Payer: BCBS MT Medicare |
$353.70
|
| Rate for Payer: BCBS MT POS |
$373.35
|
| Rate for Payer: BCBS MT Traditional |
$393.00
|
| Rate for Payer: Cash Price |
$353.70
|
| Rate for Payer: Cigna Commercial |
$373.35
|
| Rate for Payer: Cigna Medicare |
$353.70
|
| Rate for Payer: Medicaid All Medicaid |
$361.56
|
| Rate for Payer: Medicare All Medicare |
$275.10
|
| Rate for Payer: Monida Allegiance |
$373.35
|
| Rate for Payer: Monida First Choice Health |
$381.21
|
| Rate for Payer: Monida Montana Health Co-op |
$373.35
|
| Rate for Payer: Monida PacificSource |
$373.35
|
|
|
PRO FEE REPAIR SIMPLE FACE...7.6-12.5
|
Professional
|
Both
|
$176.00
|
|
|
Service Code
|
HCPCS 12015 AQ
|
| Hospital Charge Code |
712015
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$123.20 |
| Max. Negotiated Rate |
$176.00 |
| Rate for Payer: Aetna Commercial |
$167.20
|
| Rate for Payer: Aetna Medicare |
$158.40
|
| Rate for Payer: BCBS MT CHIP |
$158.40
|
| Rate for Payer: BCBS MT Closed Plan Network |
$167.20
|
| Rate for Payer: BCBS MT HealthLink |
$158.40
|
| Rate for Payer: BCBS MT Medicare |
$158.40
|
| Rate for Payer: BCBS MT POS |
$167.20
|
| Rate for Payer: BCBS MT Traditional |
$176.00
|
| Rate for Payer: Cash Price |
$158.40
|
| Rate for Payer: Cigna Commercial |
$167.20
|
| Rate for Payer: Cigna Medicare |
$158.40
|
| Rate for Payer: Medicaid All Medicaid |
$161.92
|
| Rate for Payer: Medicare All Medicare |
$123.20
|
| Rate for Payer: Monida Allegiance |
$167.20
|
| Rate for Payer: Monida First Choice Health |
$170.72
|
| Rate for Payer: Monida Montana Health Co-op |
$167.20
|
| Rate for Payer: Monida PacificSource |
$167.20
|
|
|
PRO FEE REPAIR SIMPLE S/N/A/G/T/E12.6-20
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
HCPCS 12005 AQ
|
| Hospital Charge Code |
712005
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$123.90 |
| Max. Negotiated Rate |
$177.00 |
| Rate for Payer: Aetna Commercial |
$168.15
|
| Rate for Payer: Aetna Medicare |
$159.30
|
| Rate for Payer: BCBS MT CHIP |
$159.30
|
| Rate for Payer: BCBS MT Closed Plan Network |
$168.15
|
| Rate for Payer: BCBS MT HealthLink |
$159.30
|
| Rate for Payer: BCBS MT Medicare |
$159.30
|
| Rate for Payer: BCBS MT POS |
$168.15
|
| Rate for Payer: BCBS MT Traditional |
$177.00
|
| Rate for Payer: Cash Price |
$159.30
|
| Rate for Payer: Cigna Commercial |
$168.15
|
| Rate for Payer: Cigna Medicare |
$159.30
|
| Rate for Payer: Medicaid All Medicaid |
$162.84
|
| Rate for Payer: Medicare All Medicare |
$123.90
|
| Rate for Payer: Monida Allegiance |
$168.15
|
| Rate for Payer: Monida First Choice Health |
$171.69
|
| Rate for Payer: Monida Montana Health Co-op |
$168.15
|
| Rate for Payer: Monida PacificSource |
$168.15
|
|
|
PRO FEE REPAIR S/N/AX/G/T >30CM
|
Professional
|
Both
|
$272.00
|
|
|
Service Code
|
HCPCS 12007 AQ
|
| Hospital Charge Code |
782007
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$190.40 |
| Max. Negotiated Rate |
$272.00 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna Medicare |
$244.80
|
| Rate for Payer: BCBS MT CHIP |
$244.80
|
| Rate for Payer: BCBS MT Closed Plan Network |
$258.40
|
| Rate for Payer: BCBS MT HealthLink |
$244.80
|
| Rate for Payer: BCBS MT Medicare |
$244.80
|
| Rate for Payer: BCBS MT POS |
$258.40
|
| Rate for Payer: BCBS MT Traditional |
$272.00
|
| Rate for Payer: Cash Price |
$244.80
|
| Rate for Payer: Cigna Commercial |
$258.40
|
| Rate for Payer: Cigna Medicare |
$244.80
|
| Rate for Payer: Medicaid All Medicaid |
$250.24
|
| Rate for Payer: Medicare All Medicare |
$190.40
|
| Rate for Payer: Monida Allegiance |
$258.40
|
| Rate for Payer: Monida First Choice Health |
$263.84
|
| Rate for Payer: Monida Montana Health Co-op |
$258.40
|
| Rate for Payer: Monida PacificSource |
$258.40
|
|
|
PRO FEE REPAIR WOUND COMPLEX 1.1-2.5CM
|
Professional
|
Both
|
$461.00
|
|
|
Service Code
|
HCPCS 13131 AQ
|
| Hospital Charge Code |
713131
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$322.70 |
| Max. Negotiated Rate |
$461.00 |
| Rate for Payer: Aetna Commercial |
$437.95
|
| Rate for Payer: Aetna Medicare |
$414.90
|
| Rate for Payer: BCBS MT CHIP |
$414.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$437.95
|
| Rate for Payer: BCBS MT HealthLink |
$414.90
|
| Rate for Payer: BCBS MT Medicare |
$414.90
|
| Rate for Payer: BCBS MT POS |
$437.95
|
| Rate for Payer: BCBS MT Traditional |
$461.00
|
| Rate for Payer: Cash Price |
$414.90
|
| Rate for Payer: Cigna Commercial |
$437.95
|
| Rate for Payer: Cigna Medicare |
$414.90
|
| Rate for Payer: Medicaid All Medicaid |
$424.12
|
| Rate for Payer: Medicare All Medicare |
$322.70
|
| Rate for Payer: Monida Allegiance |
$437.95
|
| Rate for Payer: Monida First Choice Health |
$447.17
|
| Rate for Payer: Monida Montana Health Co-op |
$437.95
|
| Rate for Payer: Monida PacificSource |
$437.95
|
|
|
PRO FEE REPAIR WOUND INT=< 2.5
|
Professional
|
Both
|
$324.00
|
|
|
Service Code
|
HCPCS 12051 AQ
|
| Hospital Charge Code |
712051
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$226.80 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$307.80
|
| Rate for Payer: Aetna Medicare |
$291.60
|
| Rate for Payer: BCBS MT CHIP |
$291.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$307.80
|
| Rate for Payer: BCBS MT HealthLink |
$291.60
|
| Rate for Payer: BCBS MT Medicare |
$291.60
|
| Rate for Payer: BCBS MT POS |
$307.80
|
| Rate for Payer: BCBS MT Traditional |
$324.00
|
| Rate for Payer: Cash Price |
$291.60
|
| Rate for Payer: Cigna Commercial |
$307.80
|
| Rate for Payer: Cigna Medicare |
$291.60
|
| Rate for Payer: Medicaid All Medicaid |
$298.08
|
| Rate for Payer: Medicare All Medicare |
$226.80
|
| Rate for Payer: Monida Allegiance |
$307.80
|
| Rate for Payer: Monida First Choice Health |
$314.28
|
| Rate for Payer: Monida Montana Health Co-op |
$307.80
|
| Rate for Payer: Monida PacificSource |
$307.80
|
|
|
PRO FEE REPAIR WOUND SIMPLE 2.5CM/LESS
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS 12011 AQ
|
| Hospital Charge Code |
712011
|
|
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 WOUND SIMPLE 2.6-5.0CM
|
Professional
|
Both
|
$109.00
|
|
|
Service Code
|
HCPCS 12013 AQ
|
| Hospital Charge Code |
712013
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$76.30 |
| Max. Negotiated Rate |
$109.00 |
| Rate for Payer: Aetna Commercial |
$103.55
|
| Rate for Payer: Aetna Medicare |
$98.10
|
| Rate for Payer: BCBS MT CHIP |
$98.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$103.55
|
| Rate for Payer: BCBS MT HealthLink |
$98.10
|
| Rate for Payer: BCBS MT Medicare |
$98.10
|
| Rate for Payer: BCBS MT POS |
$103.55
|
| Rate for Payer: BCBS MT Traditional |
$109.00
|
| Rate for Payer: Cash Price |
$98.10
|
| Rate for Payer: Cigna Commercial |
$103.55
|
| Rate for Payer: Cigna Medicare |
$98.10
|
| Rate for Payer: Medicaid All Medicaid |
$100.28
|
| Rate for Payer: Medicare All Medicare |
$76.30
|
| Rate for Payer: Monida Allegiance |
$103.55
|
| Rate for Payer: Monida First Choice Health |
$105.73
|
| Rate for Payer: Monida Montana Health Co-op |
$103.55
|
| Rate for Payer: Monida PacificSource |
$103.55
|
|
|
PRO FEE REPAIR WOUND SIMPLE 5.1-7.5CM
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
HCPCS 12014 AQ
|
| Hospital Charge Code |
712014
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$97.30 |
| Max. Negotiated Rate |
$139.00 |
| Rate for Payer: Aetna Commercial |
$132.05
|
| Rate for Payer: Aetna Medicare |
$125.10
|
| Rate for Payer: BCBS MT CHIP |
$125.10
|
| Rate for Payer: BCBS MT Closed Plan Network |
$132.05
|
| Rate for Payer: BCBS MT HealthLink |
$125.10
|
| Rate for Payer: BCBS MT Medicare |
$125.10
|
| Rate for Payer: BCBS MT POS |
$132.05
|
| Rate for Payer: BCBS MT Traditional |
$139.00
|
| Rate for Payer: Cash Price |
$125.10
|
| Rate for Payer: Cigna Commercial |
$132.05
|
| Rate for Payer: Cigna Medicare |
$125.10
|
| Rate for Payer: Medicaid All Medicaid |
$127.88
|
| Rate for Payer: Medicare All Medicare |
$97.30
|
| Rate for Payer: Monida Allegiance |
$132.05
|
| Rate for Payer: Monida First Choice Health |
$134.83
|
| Rate for Payer: Monida Montana Health Co-op |
$132.05
|
| Rate for Payer: Monida PacificSource |
$132.05
|
|
|
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
|
$184.00
|
|
|
Service Code
|
HCPCS 20600
|
| Hospital Charge Code |
720600
|
|
Hospital Revenue Code
|
964
|
| Min. Negotiated Rate |
$128.80 |
| Max. Negotiated Rate |
$184.00 |
| Rate for Payer: Aetna Commercial |
$174.80
|
| Rate for Payer: Aetna Medicare |
$165.60
|
| Rate for Payer: BCBS MT CHIP |
$165.60
|
| Rate for Payer: BCBS MT Closed Plan Network |
$174.80
|
| Rate for Payer: BCBS MT HealthLink |
$165.60
|
| Rate for Payer: BCBS MT Medicare |
$165.60
|
| Rate for Payer: BCBS MT POS |
$174.80
|
| Rate for Payer: BCBS MT Traditional |
$184.00
|
| Rate for Payer: Cash Price |
$165.60
|
| Rate for Payer: Cigna Commercial |
$174.80
|
| Rate for Payer: Cigna Medicare |
$165.60
|
| Rate for Payer: Medicaid All Medicaid |
$169.28
|
| Rate for Payer: Medicare All Medicare |
$128.80
|
| Rate for Payer: Monida Allegiance |
$174.80
|
| Rate for Payer: Monida First Choice Health |
$178.48
|
| Rate for Payer: Monida Montana Health Co-op |
$174.80
|
| Rate for Payer: Monida PacificSource |
$174.80
|
|
|
PRO FEE STRAPPING OF HAND/FINGER
|
Professional
|
Both
|
$101.00
|
|
|
Service Code
|
HCPCS 29280
|
| Hospital Charge Code |
729280
|
|
Hospital Revenue Code
|
981
|
| Min. Negotiated Rate |
$70.70 |
| Max. Negotiated Rate |
$101.00 |
| Rate for Payer: Aetna Commercial |
$95.95
|
| Rate for Payer: Aetna Medicare |
$90.90
|
| Rate for Payer: BCBS MT CHIP |
$90.90
|
| Rate for Payer: BCBS MT Closed Plan Network |
$95.95
|
| Rate for Payer: BCBS MT HealthLink |
$90.90
|
| Rate for Payer: BCBS MT Medicare |
$90.90
|
| Rate for Payer: BCBS MT POS |
$95.95
|
| Rate for Payer: BCBS MT Traditional |
$101.00
|
| Rate for Payer: Cash Price |
$90.90
|
| Rate for Payer: Cigna Commercial |
$95.95
|
| Rate for Payer: Cigna Medicare |
$90.90
|
| Rate for Payer: Medicaid All Medicaid |
$92.92
|
| Rate for Payer: Medicare All Medicare |
$70.70
|
| Rate for Payer: Monida Allegiance |
$95.95
|
| Rate for Payer: Monida First Choice Health |
$97.97
|
| Rate for Payer: Monida Montana Health Co-op |
$95.95
|
| Rate for Payer: Monida PacificSource |
$95.95
|
|
|
PROFEE STRESS ECHO TREADMILL
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
HCPCS 93350 26
|
| Hospital Charge Code |
50002428
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$184.80 |
| Max. Negotiated Rate |
$256.08 |
| Rate for Payer: Aetna Commercial |
$250.80
|
| Rate for Payer: Aetna Medicare |
$237.60
|
| Rate for Payer: Cash Price |
$237.60
|
| Rate for Payer: Medicaid All Medicaid |
$242.88
|
| Rate for Payer: Medicare All Medicare |
$184.80
|
| Rate for Payer: Monida Allegiance |
$250.80
|
| Rate for Payer: Monida First Choice Health |
$256.08
|
| Rate for Payer: Monida Montana Health Co-op |
$250.80
|
| Rate for Payer: Monida PacificSource |
$250.80
|
|
|
PROFEE TCD STD ICR ART VEN-ART SHNT
|
Professional
|
Both
|
$229.00
|
|
|
Service Code
|
HCPCS 93893 26
|
| Hospital Charge Code |
50002433
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$160.30 |
| Max. Negotiated Rate |
$222.13 |
| Rate for Payer: Aetna Commercial |
$217.55
|
| Rate for Payer: Aetna Medicare |
$206.10
|
| Rate for Payer: Cash Price |
$206.10
|
| Rate for Payer: Medicaid All Medicaid |
$210.68
|
| Rate for Payer: Medicare All Medicare |
$160.30
|
| Rate for Payer: Monida Allegiance |
$217.55
|
| Rate for Payer: Monida First Choice Health |
$222.13
|
| Rate for Payer: Monida Montana Health Co-op |
$217.55
|
| Rate for Payer: Monida PacificSource |
$217.55
|
|
|
PRO FEE TRIGGER POINT INJ 3+ 20553
|
Professional
|
Both
|
$213.00
|
|
|
Service Code
|
HCPCS 20553
|
| Hospital Charge Code |
720553
|
|
Hospital Revenue Code
|
964
|
| 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
|
|
