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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
$128.82 / $1,047.13 / $1,047.13
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,047.13 / $1,047.13 / $1,230.27
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$891.25 / $1,122.02 / $1,202.26
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,122.02 / $1,122.02 / $1,202.26
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $223.87 / $309.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$309.03 / $457.09 / $1,047.13
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$776.25 / $977.24 / $1,659.59
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$302.00 / $870.96 / $1,047.13
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $363.08 / $1,047.13
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $208.93 / $309.03
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$338.84 / $457.09 / $2,187.76
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$302.00 / $489.78 / $794.33
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $302.00 / $1,000.00