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Montana rates for HCPCS 13122

Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$565.79 / $565.79 / $565.79
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$72.81 / $108.73 / $144.72
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$64,999.99 / $77,999.99 / $94,999.99
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.50 / $128.82 / $199.80
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$128.82 / $128.82 / $128.82
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.50 / $143.16 / $220.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$72.31 / $121.80 / $200.85
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$109.50 / $152.43 / $240.20
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$188.49 / $220.67 / $239.37