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Nebraska rates for HCPCS Q4104

Integra bilayer matrix wound dressing (BMWD), per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$51.00 / $53.76 / $53.76
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $51.00 / $56.10
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$49.08 / $57.74 / $57.74
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$54.85 / $57.74 / $60.85
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$31.31 / $41.00 / $51.00
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.00 / $59.75 / $78.59
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$49.53 / $75.00 / $110.95
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$49.79 / $53.76 / $119.25
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$50.10 / $59.75 / $76.68
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.41 / $59.75 / $83.06
Oscar Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$29.90 / $29.90 / $36.29
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$48.45 / $51.00 / $56.10