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Nebraska rates for HCPCS Q4122

DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$96.80 / $96.80 / $121.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$96.80 / $96.80 / $102.85
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$78.56 / $116.70 / $156.41
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$102.85 / $102.85 / $102.85
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$96.80 / $150.04 / $188.76
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$110.00 / $110.00 / $121.03
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$132.11 / $132.11 / $132.11
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$132.11 / $132.11 / $132.11
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$104.50 / $110.00 / $121.03