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Missouri 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 / $12.87 / $15.75
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.74 / $14.99
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9.91 / $12.41 / $16.70
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.78 / $11.78 / $12.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $15.91
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.63 / $15.00 / $34.81
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.38 / $12.38 / $6,184.50
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $15.28