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Texas rates for HCPCS Q4103

Oasis burn matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.99
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.54 / $4.05 / $7.78
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.00 / $121.37 / $121.37
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.78 / $12.49 / $12.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.49
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.00 / $100.00 / $100.00
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6,184.50 / $6,184.50 / $6,184.50
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.62 / $12.38 / $22.50
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $15.61
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.90 / $14.90 / $205.54
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$4.62 / $12.49 / $21.86
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $15.13
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.65
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.38 / $12.49 / $16.86