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Oasis Ultra Tri-Layer Wound Matrix

Washington 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 $13 · 10th–90th $2$3800%20%10th90th$13Professionalmedian $3 · 10th–90th $3$1260%20%40%10th90th$3$5.0$20.0$100.0$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
$2.75
Median
$2.75
Typical High
$2.75
Aetna
Setting
Professional
Modifier
Global
Typical Low
$2.51
Median
$2.51
Typical High
$41.69
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$12.30
Median
$125.89
Typical High
$125.89
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$141.25
Cigna
Setting
Facility
Modifier
Global
Typical Low
$50.12
Median
$169.82
Typical High
$245.47
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$17.78
Median
$25.70
Typical High
$588.84
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$17.78
Median
$20.42
Typical High
$25.70
Molina
Setting
Professional
Modifier
Global
Typical Low
$50.12
Median
$50.12
Typical High
$75.86
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$2.45
Median
$2.51
Typical High
$5.13
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$3.72
Median
$11.22
Typical High
$14.79
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$3.02
Median
$3.72
Typical High
$3.72
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$11.22
Median
$12.30
Typical High
$125.89
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$141.25
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$10.23
Median
$154.88
Typical High
$295.12