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Nebraska rates for HCPCS Q4126

MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$61.66 / $63.10 / $128.82
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$61.66 / $63.10 / $87.10
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$52.48 / $67.61 / $70.79
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$66.07 / $67.61 / $70.79
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $208.93 / $229.09
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $64.57 / $89.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$60.26 / $87.10 / $117.49
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$60.26 / $60.26 / $93.33
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.61 / $75.86 / $97.72
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $208.93 / $309.03
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$67.61 / $97.72 / $147.91
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$63.10 / $104.71 / $165.96
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$63.10 / $81.28 / $125.89