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Nebraska rates for HCPCS Q4204

XWRAP, 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 / $3,715.35 / $3,715.35
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,715.35 / $3,715.35 / $4,265.80
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,511.89 / $3,801.89 / $4,570.88
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,890.45 / $3,981.07 / $4,168.69
Cigna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $223.87 / $309.03
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,019.95 / $3,715.35 / $4,570.88
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$3,548.13 / $4,265.80 / $7,244.36
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,951.21 / $3,801.89 / $4,168.69
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$3,548.13 / $4,466.84 / $4,570.88
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$169.82 / $208.93 / $309.03
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$4,466.84 / $9,332.54 / $9,332.54
United
Facility/Professional
Facility
Modifier
Low / Median / High Price
$2,951.21 / $4,786.30 / $7,762.47
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$125.89 / $2,818.38 / $2,951.21