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Texas rates for HCPCS Q4124

OASIS ultra tri-layer wound matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.64
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$80.00 / $121.37 / $121.37
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.35 / $2.49 / $2.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.00 / $85.00 / $85.00
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,398.28 / $5,398.28 / $5,398.28
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.48 / $2.49 / $5.47
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $3.11
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.68 / $15.32 / $302.94
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.49 / $2.49 / $7.12
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $9.78
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.54
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $10.22