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Texas 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
$735.05 / $735.05 / $742.40
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $821.34
Christus
Facility/Professional
Facility
Modifier
Low / Median / High Price
$121.37 / $121.37 / $127.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$693.44 / $735.05 / $735.05
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $735.05
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,887.00 / $4,295.12 / $4,440.00
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,295.12 / $4,295.12 / $8,436.00
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$742.40 / $813.21 / $1,558.31
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $918.81
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$148.10 / $302.94 / $2,188.88
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$735.05 / $735.05 / $1,555.34
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $1,040.16
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $744.61
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$735.05 / $735.05 / $813.21