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California 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
$2.49 / $2.49 / $2.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.88
Anthem BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.42 / $2.88 / $4.87
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.48 / $2.58 / $9.81
Blue Shield
Facility/Professional
Facility
Modifier
Low / Median / High Price
$14.65 / $20.91 / $28.57
Blue Shield
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.30 / $9.00 / $22.50
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.35 / $2.35 / $2.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $3.05
Contra Costa Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$9.11 / $10.22 / $13.79
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.33 / $3.11 / $5.73
Lucent Health
Facility/Professional
Facility
Modifier
Low / Median / High Price
$75.00 / $85.00 / $85.00
Lucent Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$5,398.28 / $5,398.28 / $5,398.28
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$10.02 / $14.30 / $70.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.49 / $2.89 / $12.78
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $12.78
The Alliance
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1.99 / $9.11 / $10.93
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $5.45