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Pennsylvania rates for HCPCS Q4256

MLG-Complete, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$741.31 / $741.31 / $741.31
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $741.31 / $812.83
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,548.82 / $1,862.09 / $2,290.87
Capital Blue Cross
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,862.09 / $1,862.09 / $1,862.09
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$741.31 / $741.31 / $741.31
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $741.31 / $758.58
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.88 / $1,621.81 / $1,905.46
Geisinger
Facility/Professional
Professional
Modifier
Low / Median / High Price
$120.23 / $158.49 / $218.78
Martin's Point
Facility/Professional
Facility
Modifier
Low / Median / High Price
$741.31 / $741.31 / $741.31
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$741.31 / $741.31 / $851.14
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$0.60 / $229.09 / $245.47
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $933.25 / $1,905.46