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Arizona 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
Facility
Modifier
Low / Median / High Price
$2.73 / $4.98 / $4.98
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.50 / $2.73
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7.33 / $17.30 / $42.81
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.44 / $9.16 / $21.64
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 / $2.49
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.48 / $3.00 / $15.00
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.48 / $2.48 / $9.09
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49