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Oasis Ultra Tri-Layer Wound Matrix

Idaho rates for HCPCS Q4124

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

Rates data updated July 2026.

Facilitymedian $13 · 10th–90th $3$1450%10%10th90th$13Professionalmedian $3 · 10th–90th $3$2190%20%10th90th$3$5.0$20.0$100.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$117.49
Aetna
Setting
Professional
Modifier
Global
Typical Low
$2.51
Median
$2.51
Typical High
$4.57
BCBS
Setting
Facility
Modifier
Global
Typical Low
$10.23
Median
$13.49
Typical High
$19.05
BCBS
Setting
Professional
Modifier
Global
Typical Low
$12.88
Median
$12.88
Typical High
$12.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$141.25
Median
$144.54
Typical High
$323.59
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Moda Health
Setting
Facility
Modifier
Global
Typical Low
$2.51
Median
$3.39
Typical High
$112.20
Moda Health
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$218.78
Typical High
$251.19
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$30.20
Typical High
$77.62
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$151.36
Typical High
$151.36
Select Health
Setting
Facility
Modifier
Global
Typical Low
$117.49
Median
$117.49
Typical High
$302.00
Select Health
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$147.91
Typical High
$234.42
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89