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Georgia 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
$12.02 / $12.02 / $12.02
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.02 / $12.02 / $15.85
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.59 / $15.49 / $15.49
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.75 / $11.75 / $12.59
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.59 / $12.59 / $14.79
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$46.77 / $128.82 / $186.21
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$13.18 / $24.55 / $34.67
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.59 / $16.22 / $125.89