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Alaska rates for HCPCS Q4124

OASIS ultra tri-layer wound matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4.62 / $4.62 / $4.62
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $3.52
Moda Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.48 / $4.62 / $6.61
Moda Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $3.74
Premera BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$15.42 / $24.00 / $52.64
Premera BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$12.45 / $16.50 / $18.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.49 / $6.47 / $33.95
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $11.13 / $18.00
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3.74 / $3.74 / $7.47