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West Virginia rates for HCPCS Q4124

OASIS ultra tri-layer wound matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1.74 / $2.50 / $2.50
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.50 / $2.61
CareSource
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.49 / $2.49 / $3.74
CareSource
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $5.77
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2.35 / $85.00 / $85.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $2.49
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2.49 / $2.49 / $16.19