Q4120 Matristem burn matrix

Matristem burn matrix, per square centimeter

Payer policies and prior authorization for Q4120

Payer coverage policies that name Q4120

Q4120 appears in 1 coverage policy from Aetna.

PayerPolicyRole in policyReviewedDocument
AetnaMohs Micrographic Surgery (0383)listed, no stance (range Q4100-Q4255)May 28, 2026payer document

Medicaid fee-for-service

  • WY: $0.00 (professional), effective Jan 1, 2017

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.