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Oasis Burn Matrix

South Dakota 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 $13 · 10th–90th $12$210%50%10th90th$13Professionalmedian $13 · 10th–90th $13$1200%50%10th90th$13$5.0$20.0$100.0$500.0$2.0K

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
$12.59
Aetna
Setting
Professional
Modifier
Global
Typical Low
$12.59
Median
$12.59
Typical High
$15.49
Cigna
Setting
Facility
Modifier
Global
Typical Low
$13.18
Median
$16.98
Typical High
$169.82
Cigna
Setting
Professional
Modifier
Global
Typical Low
$12.88
Median
$14.79
Typical High
$15.85
Medica
Setting
Facility
Modifier
Global
Typical Low
$12.30
Median
$20.89
Typical High
$24.55
Medica
Setting
Professional
Modifier
Global
Typical Low
$12.30
Median
$12.30
Typical High
$6,165.95
Midlands
Setting
Professional
Modifier
Global
Typical Low
$14.79
Median
$14.79
Typical High
$15.14
Midlands
Setting
Facility
Modifier
Global
Typical Low
$13.18
Median
$169.82
Typical High
$204.17
Midlands
Setting
Professional
Modifier
Global
Typical Low
$11.48
Median
$11.48
Typical High
$11.48
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$14.13
Median
$14.13
Typical High
$14.13
United
Setting
Professional
Modifier
Global
Typical Low
$12.59
Median
$125.89
Typical High
$239.88
Wellmark
Setting
Facility
Modifier
Global
Typical Low
$12.59
Median
$12.59
Typical High
$12.59
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$12.59
Median
$12.59
Typical High
$12.59