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West Virginia 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
$8.67 / $12.62 / $12.62
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.62 / $13.12
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$12.49 / $12.49 / $18.73
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $28.96
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.78 / $85.00 / $85.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $18.09