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Oasis Ultra Tri-Layer Wound Matrix

Montana 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 October 2026.

How much does Oasis Ultra Tri-Layer Wound Matrix cost?

$79.43

Typical negotiated rate. In Montana, October 2026.

Insurers have agreed to pay about $79.43 for this service. The price depends on where it is billed: about $79.43 from a physician practice, and about $148 from a hospital or other facility.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 5 insurance carriers under federal price transparency rules.

Prices by location type

Billed byTypicalRange
Physician practiceA doctor's office, clinic or independent provider$79.43$10.47 to $126
FacilityA hospital or hospital-owned outpatient department$148$10.47 to $158

How much rates vary

Facilitymedian $148 · 10th to 90th $10 to $209Professionalmedian $79 · 10th to 90th $10 to $126
$5$10$20$50$100$200facility $148professional $79

Distribution of negotiated rates across all payers (price axis is log-scale). Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Professional
Modifier
None
Typical Low
$2.51
Median
$2.57
Typical High
$3.09
Cigna
Setting
Facility
Modifier
None
Typical Low
$10.47
Median
$10.47
Typical High
$204.17
Cigna
Setting
Professional
Modifier
None
Typical Low
$10.47
Median
$10.47
Typical High
$10.47
MountainHealth Co-op
Setting
Facility
Modifier
None
Typical Low
$125.89
Median
$158.49
Typical High
$208.93
MountainHealth Co-op
Setting
Professional
Modifier
None
Typical Low
$125.89
Median
$141.25
Typical High
$158.49
Providence
Setting
Facility
Modifier
None
Typical Low
$10.47
Median
$10.47
Typical High
$204.17
Providence
Setting
Professional
Modifier
None
Typical Low
$10.47
Median
$12.88
Typical High
$79.43
United
Setting
Professional
Modifier
None
Typical Low
$125.89
Median
$125.89
Typical High
$125.89

Where Montana sits

The same service costs 50.1 times more in Massachusetts than in Indiana. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Montana· 23rd of 51

$79.43

MA $126IN $2.51

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.