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Nebraska rates for HCPCS Q4203

Derma-Gide, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$871.37 / $1,052.89 / $1,052.89
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,158.18
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,013.17 / $1,191.97 / $1,191.97
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$937.15 / $1,132.35 / $1,191.97
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$1,052.89 / $1,052.89 / $1,052.89
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$281.83 / $360.22 / $1,052.89
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$463.10 / $974.89 / $1,655.60
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$300.18 / $871.37 / $997.27
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$342.21 / $360.22 / $462.28
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$284.31 / $360.22 / $1,045.64
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,000.25 / $1,052.89 / $1,158.18