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Oasis Burn Matrix

Ohio rates for HCPCS Q4103

Oasis burn matrix, per sq cm (add-on, list separately in addition to primary procedure)

Rates data updated July 2026.

Facilitymedian $102 · 10th–90th $13$3160%20%10th90th$102Professionalmedian $13 · 10th–90th $13$1260%50%10th90th$13$2.0$10.0$50.0$200.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$12.59
Median
$12.59
Typical High
$14.45
Aetna
Setting
Professional
Modifier
Global
Typical Low
$12.59
Median
$12.59
Typical High
$13.80
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$12.59
Median
$14.79
Typical High
$28.84
CareSource
Setting
Facility
Modifier
Global
Typical Low
$12.59
Median
$12.59
Typical High
$12.59
CareSource
Setting
Professional
Modifier
Global
Typical Low
$12.59
Median
$12.59
Typical High
$16.98
Cigna
Setting
Facility
Modifier
Global
Typical Low
$239.88
Median
$269.15
Typical High
$416.87
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Medical Mutual of Ohio
Setting
Facility
Modifier
Global
Typical Low
$181.97
Median
$269.15
Typical High
$389.05
Medical Mutual of Ohio
Setting
Professional
Modifier
Global
Typical Low
$27.54
Median
$125.89
Typical High
$125.89
Molina
Setting
Professional
Modifier
Global
Typical Low
$13.80
Median
$87.10
Typical High
$128.82
SummaCare
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$141.25
Typical High
$158.49
SummaCare
Setting
Professional
Modifier
Global
Typical Low
$11.22
Median
$15.14
Typical High
$30.90
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$275.42
United
Setting
Professional
Modifier
Global
Typical Low
$89.13
Median
$125.89
Typical High
$125.89