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Wyoming 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 / $12.38 / $12.38
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $13.62 / $13.74
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.75 / $15.00 / $15.00
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$11.78 / $11.78 / $11.78
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $17.68 / $17.68
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.49 / $12.49 / $12.49