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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 July 2026.

Facilitymedian $10 · 10th–90th $3$280%20%40%10th90th$10Professionalmedian $3 · 10th–90th $3$1260%20%40%10th90th$3$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
Professional
Modifier
Global
Typical Low
$2.51
Median
$2.75
Typical High
$10.23
Cigna
Setting
Facility
Modifier
Global
Typical Low
$10.47
Median
$10.47
Typical High
$144.54
Cigna
Setting
Professional
Modifier
Global
Typical Low
$10.47
Median
$125.89
Typical High
$125.89
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$9.55
Median
$9.55
Typical High
$18.20
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$9.55
Median
$9.55
Typical High
$18.20
Providence
Setting
Facility
Modifier
Global
Typical Low
$2.51
Median
$9.33
Typical High
$181.97
Providence
Setting
Professional
Modifier
Global
Typical Low
$10.47
Median
$79.43
Typical High
$125.89
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89