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Oasis Ultra Tri-Layer Wound Matrix

New Hampshire 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 $20 · 10th–90th $3$2690%20%10th90th$20Professionalmedian $3 · 10th–90th $3$140%50%90th$3$5.0$10.0$20.0$50.0$100.0$200.0$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
$2.51
Median
$2.51
Typical High
$131.83
Aetna
Setting
Professional
Modifier
Global
Typical Low
$2.51
Median
$2.51
Typical High
$3.02
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$12.88
Median
$12.88
Typical High
$14.45
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$251.19
Typical High
$338.84
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Harvard Pilgrim
Setting
Professional
Modifier
Global
Typical Low
$2.51
Median
$2.51
Typical High
$4.68
United
Setting
Facility
Modifier
Global
Typical Low
$208.93
Median
$208.93
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$2.51
Median
$11.48
Typical High
$125.89
Well Sense
Setting
Facility
Modifier
Global
Typical Low
$14.79
Median
$79.43
Typical High
$87.10