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

Zenith amniotic membrane psc

Payers reporting HCPCS Q4253

Payer pricing summary

Low

Average

$218

Median

$174

High

$742

Payer rate distribution

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#
1	UnitedHealthcare fee schedule · outpatient · +9 other terms	428	$210	$237	$200	85%	—	$26 – $1.8k
2	Cigna fee schedule · outpatient · +7 other terms	287	$199	$305	$362	119%	—	$67 – $6.1k
3	Aetna fee schedule · outpatient · +9 other terms	238	$133	$182	$152	83%	—	$69 – $1.4k
4	Blue Cross Blue Shield fee schedule · outpatient · +7 other terms	196	$121	$217	$496	229%	—	$1 – $4.3k
5	Humana fee schedule · outpatient · +7 other terms	184	$116	$176	$314	178%	—	$48 – $1.8k
6	Molina fee schedule · outpatient · +7 other terms	84	$200	$254	$343	135%	—	$51 – $3.4k
7	Caresource fee schedule · outpatient · +3 other terms	61	$100	$110	$61	56%	—	$48 – $213
8	Anthem facility · fee schedule · outpatient · +5 other terms	55	$161	$187	$210	112%	—	$48 – $1.8k
9	WellCare fee schedule · outpatient · +6 other terms	49	$135	$133	$22	17%	—	$72 – $171
10	Ambetter fee schedule · outpatient · +4 other terms	42	$234	$251	$109	43%	—	$78 – $685
11	Kaiser fee schedule · outpatient · +4 other terms	42	$207	$268	$180	67%	—	$125 – $1000
12	Devoted fee schedule · outpatient · +3 other terms	35	$125	$125	$8	6%	—	$116 – $139
13	Optum fee schedule · outpatient · +2 other terms	32	$125	$173	$91	53%	—	$113 – $459
14	Bcbs Tx fee schedule · outpatient	30	$8	$8	$3	31%	—	$6 – $30
15	Healthpartners fee schedule · outpatient · +1 other terms	19	$143	$142	$4	3%	—	$131 – $146
16	Oscar facility · fee schedule · outpatient · +2 other terms	19	$182	$168	$47	28%	—	$103 – $234
17	Medical Mutual facility · fee schedule · outpatient · +3 other terms	18	$163	$198	$85	43%	—	$64 – $468
18	Medicare fee schedule · outpatient · +1 other terms	18	$125	$125	—	—	—	$125 – $125
19	Highmark fee schedule · outpatient · +4 other terms	16	$88	$173	$372	215%	—	$83 – $3.4k
20	Wellmark fee schedule · both · +1 other terms	14	$72	$77	$32	42%	—	$72 – $276
21	Aetna Better Health fee schedule · outpatient · +2 other terms	11	$251	$372	$159	43%	—	$251 – $583
22	Bcbs Nj fee schedule · outpatient	11	$111	$111	$17	15%	—	$79 – $119
23	Tricare fee schedule · outpatient · +1 other terms	11	$113	$118	$10	8%	—	$113 – $148
24	Medica fee schedule · outpatient · +4 other terms	10	$955	$963	$240	25%	—	$579 – $1.2k
25	Regence fee schedule · outpatient · +4 other terms	10	$146	$146	$4	3%	—	$140 – $156

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