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Indiana 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
$12.50 / $12.62 / $12.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.62
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.49 / $12.49 / $24.11
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $17.73
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.49 / $12.49 / $18.73
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $14.99
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $14.98
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $15.49