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Oasis Ultra Tri-Layer Wound Matrix

Michigan 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 $14 · 10th–90th $3$1260%20%40%10th90th$14Professionalmedian $3 · 10th–90th $3$1260%50%10th90th$3$2.0$5.0$10.0$20.0$50.0$100.0$200.0

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
$2.57
Median
$2.57
Typical High
$2.57
Aetna
Setting
Professional
Modifier
Global
Typical Low
$2.51
Median
$2.51
Typical High
$2.63
BCBS
Setting
Facility
Modifier
Global
Typical Low
$21.88
Median
$125.89
Typical High
$125.89
BCBS
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$125.89
Typical High
$134.90
Cigna
Setting
Professional
Modifier
Global
Typical Low
$10.23
Median
$125.89
Typical High
$125.89
Health Alliance Plan
Setting
Facility
Modifier
Global
Typical Low
$3.72
Median
$15.14
Typical High
$42.66
Health Alliance Plan
Setting
Professional
Modifier
Global
Typical Low
$2.00
Median
$15.85
Typical High
$138.04
Priority Health
Setting
Professional
Modifier
Global
Typical Low
$9.33
Median
$9.77
Typical High
$199.53
United
Setting
Facility
Modifier
Global
Typical Low
$16.22
Median
$102.33
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$120.23
Median
$125.89
Typical High
$125.89