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Tennessee 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 / $12.49 / $21.67
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $13.12
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 / $12.49
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.00 / $100.00 / $100.00
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6,184.50 / $6,184.50 / $6,184.50
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.12 / $12.49 / $12.49