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Oasis Ultra Tri-Layer Wound Matrix

South Dakota 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 $3 · 10th–90th $3$180%20%40%90th$3Professionalmedian $3 · 10th–90th $3$150%20%40%10th90th$3$2.0$10.0$50.0$200.0$1.0K$5.0K

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
$15.14
Typical High
$15.14
Aetna
Setting
Professional
Modifier
Global
Typical Low
$2.51
Median
$2.51
Typical High
$3.09
Cigna
Setting
Facility
Modifier
Global
Typical Low
$12.30
Median
$15.49
Typical High
$169.82
Cigna
Setting
Professional
Modifier
Global
Typical Low
$9.33
Median
$9.33
Typical High
$11.48
Medica
Setting
Facility
Modifier
Global
Typical Low
$2.45
Median
$4.17
Typical High
$15.14
Medica
Setting
Professional
Modifier
Global
Typical Low
$2.45
Median
$2.45
Typical High
$5,370.32
Midlands
Setting
Professional
Modifier
Global
Typical Low
$2.95
Median
$2.95
Typical High
$10.96
Midlands
Setting
Facility
Modifier
Global
Typical Low
$18.20
Median
$169.82
Typical High
$204.17
Sanford Health Plan
Setting
Professional
Modifier
Global
Typical Low
$12.88
Median
$12.88
Typical High
$12.88
United
Setting
Professional
Modifier
Global
Typical Low
$14.45
Median
$125.89
Typical High
$239.88
Wellmark
Setting
Facility
Modifier
Global
Typical Low
$2.51
Median
$2.51
Typical High
$2.51
Wellmark
Setting
Professional
Modifier
Global
Typical Low
$2.51
Median
$2.51
Typical High
$2.51