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Maryland 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
$12.38 / $12.38 / $12.38
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $13.12
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.24 / $10.24 / $10.24
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.75
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $15.91
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.62 / $12.49 / $14.57
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $13.76
Wellpoint
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.48 / $12.48 / $16.36