Amniotic membrane graft, per square centimeter

Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.

Model: claude-haiku-5-5
Provider: anthropic
API: message_batches
Reasoning effort: low
Max output tokens: 4096
Prompt version (hash): 444523875572
Generated: October 20, 2026

Original text from hospital filings

AmnioExcel 4cm x 8cm disk

Payers reporting HCPCS Q4137

Payer pricing summary

Low

$66

Average

$945

Median

$602

High

$3.7k

Payer rate distribution

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#
1	UnitedHealthcare fee schedule · outpatient · +20 other terms	459	$210	$213	$179	84%	—	$1 – $3.3k
2	Cigna fee schedule · outpatient · +18 other terms	307	$175	$557	$1.7k	302%	—	$1 – $22.5k
3	Aetna fee schedule · outpatient · +22 other terms	261	$133	$212	$363	172%	—	$20 – $3.3k
4	Humana fee schedule · outpatient · +18 other terms	191	$112	$179	$236	132%	—	$1 – $3.3k
5	Blue Cross Blue Shield fee schedule · outpatient · +19 other terms	162	$135	$478	$1.7k	347%	—	$1 – $17.2k
6	Molina fee schedule · outpatient · +19 other terms	91	$200	$699	$1.1k	162%	—	$1 – $5.3k
7	Anthem facility · fee schedule · outpatient · +14 other terms	78	$158	$178	$112	63%	—	$48 – $1.2k
8	Caresource fee schedule · outpatient · +12 other terms	63	$159	$241	$332	138%	—	$1 – $3.3k
9	WellCare fee schedule · outpatient · +13 other terms	49	$135	$136	$14	10%	—	$102 – $171
10	Kaiser fee schedule · outpatient · +15 other terms	48	$252	$1.9k	$3.2k	170%	—	$125 – $16.1k
11	Ambetter fee schedule · outpatient · +10 other terms	42	$234	$255	$45	18%	—	$95 – $351
12	Devoted facility · fee schedule · outpatient · +8 other terms	36	$118	$123	$8	7%	—	$112 – $143
13	Optum fee schedule · outpatient · +9 other terms	31	$125	$472	$824	175%	—	$77 – $3.7k
14	Tricare facility · fee schedule · outpatient · +10 other terms	23	$127	$196	$380	194%	—	$109 – $3.6k
15	Oscar facility · fee schedule · outpatient · +10 other terms	22	$179	$166	$31	19%	—	$125 – $234
16	Medcost percent of total billed charges · bothfrom % of charges · +4 other terms	21	$184	$557	$491	88%	—	$0 – $1.6k
17	Regence professional · fee schedule · outpatient · +10 other terms	21	$100	$103	$11	11%	—	$100 – $153
18	Beechstreet percent of total billed charges · outpatientfrom % of charges · +2 other terms	19	$2.6k	$5.7k	$8.4k	148%	—	$201 – $42.0k
19	Healthpartners fee schedule · outpatient · +4 other terms	19	$139	$139	$3	2%	—	$131 – $142
20	Medicare fee schedule · outpatient · +8 other terms	18	$125	$125	—	—	—	$125 – $125
21	Highmark fee schedule · outpatient · +9 other terms	17	$126	$225	$488	217%	—	$119 – $3.4k
22	Medical Mutual facility · fee schedule · outpatient · +5 other terms	17	$124	$221	$126	57%	—	$64 – $468
23	Medica fee schedule · both · +13 other terms	15	$202	$190	$52	28%	—	$124 – $246
24	MultiPlan fee schedule · inpatient · +13 other terms	14	$1.3k	$2.4k	$4.0k	166%	—	$112 – $18.1k
25	Wellmark fee schedule · both · +3 other terms	14	$102	$103	$3	3%	—	$101 – $119

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