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

Cocoon membrane, per sq cm

Payers reporting HCPCS Q4264

Payer pricing summary

Low

Average

$516

Median

$218

High

$2.9k

Payer rate distribution

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#
1	UnitedHealthcare fee schedule · outpatient · +9 other terms	406	$288	$1.1k	$2.0k	187%	—	$48 – $12.3k
2	Cigna fee schedule · outpatient · +7 other terms	251	$703	$1.7k	$2.0k	122%	—	$119 – $7.6k
3	Aetna fee schedule · outpatient · +8 other terms	187	$144	$267	$321	120%	—	$69 – $1.8k
4	Blue Cross Blue Shield fee schedule · outpatient · +6 other terms	179	$125	$383	$1.4k	360%	—	$1 – $12.3k
5	Humana fee schedule · outpatient · +6 other terms	172	$244	$273	$165	60%	—	$48 – $502
6	Molina fee schedule · outpatient · +6 other terms	57	$194	$257	$382	148%	—	$51 – $3.4k
7	Anthem facility · fee schedule · outpatient · +5 other terms	54	$178	$363	$487	134%	—	$48 – $3.4k
8	Caresource fee schedule · outpatient · +3 other terms	48	$191	$211	$189	89%	—	$48 – $634
9	WellCare fee schedule · outpatient · +5 other terms	46	$138	$168	$97	58%	—	$119 – $478
10	Kaiser fee schedule · outpatient · +4 other terms	41	$207	$364	$740	204%	—	$125 – $5.8k
11	Ambetter fee schedule · outpatient · +3 other terms	38	$248	$326	$229	70%	—	$162 – $980
12	Devoted fee schedule · outpatient · +3 other terms	34	$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	Oscar facility · fee schedule · outpatient · +1 other terms	19	$234	$275	$123	45%	—	$175 – $462
16	Medicare fee schedule · outpatient · +1 other terms	18	$125	$125	—	—	—	$125 – $125
17	Medical Mutual facility · fee schedule · outpatient · +2 other terms	17	$142	$640	$491	77%	—	$64 – $1.6k
18	Highmark fee schedule · outpatient · +4 other terms	16	$592	$699	$561	80%	—	$127 – $3.5k
19	Wellmark fee schedule · both · +1 other terms	14	$2.7k	$2.6k	$373	14%	—	$373 – $2.7k
20	Bcbs Nj fee schedule · outpatient	11	$2.2k	$2.2k	$947	43%	—	$387 – $2.7k
21	Regence fee schedule · outpatient · +4 other terms	10	$146	$146	$4	3%	—	$140 – $156
22	Tricare fee schedule · outpatient · +1 other terms	10	$113	$115	$4	3%	—	$113 – $121
23	Clover fee schedule · outpatient · +2 other terms	9	$140	$243	$166	69%	—	$120 – $478
24	Medica fee schedule · both · +3 other terms	9	$3.0k	$3.0k	$27	1%	—	$2.9k – $3.0k
25	Excellus fee schedule · outpatient · +2 other terms	6	$236	$230	$60	26%	—	$127 – $351

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