Amniotic membrane allograft, 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

Esano aca, per sq cm

Payers reporting HCPCS Q4275

Payer pricing summary

Low

Average

$1.2k

Median

$867

High

$5.7k

Payer rate distribution

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#
1	UnitedHealthcare fee schedule · outpatient · +9 other terms	418	$296	$1.9k	$2.7k	142%	—	$48 – $16.7k
2	Cigna fee schedule · outpatient · +5 other terms	188	$3.4k	$6.4k	$6.6k	104%	—	$119 – $22.9k
3	Aetna fee schedule · outpatient · +8 other terms	184	$134	$974	$2.5k	252%	—	$69 – $13.0k
4	Blue Cross Blue Shield fee schedule · outpatient · +6 other terms	172	$125	$435	$1.1k	242%	—	$1 – $4.8k
5	Humana fee schedule · outpatient · +6 other terms	171	$171	$1.2k	$1.2k	104%	—	$48 – $2.8k
6	Molina fee schedule · outpatient · +6 other terms	55	$192	$251	$391	156%	—	$51 – $3.4k
7	Anthem facility · fee schedule · outpatient · +5 other terms	52	$177	$1.5k	$2.3k	150%	—	$48 – $9.7k
8	Caresource fee schedule · outpatient · +3 other terms	47	$191	$1.0k	$1.4k	137%	—	$48 – $4.5k
9	WellCare fee schedule · outpatient · +5 other terms	47	$140	$355	$708	200%	—	$119 – $2.7k
10	Kaiser fee schedule · outpatient · +4 other terms	39	$207	$267	$184	69%	—	$125 – $1000
11	Ambetter fee schedule · outpatient · +3 other terms	38	$248	$858	$1.6k	190%	—	$162 – $5.5k
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	Healthpartners fee schedule · outpatient · +1 other terms	19	$218	$216	$15	7%	—	$131 – $223
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	$4.2k	$3.9k	93%	—	$64 – $11.4k
18	Highmark fee schedule · outpatient · +4 other terms	16	$3.3k	$3.1k	$796	26%	—	$127 – $3.4k
19	Wellmark fee schedule · both · +1 other terms	14	$2.6k	$2.6k	$67	3%	—	$2.2k – $2.7k
20	Bcbs Nj fee schedule · outpatient	11	$2.3k	$2.3k	$276	12%	—	$2.1k – $2.8k
21	Oscar facility · fee schedule · outpatient · +1 other terms	11	$1.7k	$1.5k	$1.6k	103%	—	$175 – $3.3k
22	Tricare fee schedule · outpatient · +1 other terms	11	$113	$118	$10	8%	—	$113 – $148
23	Regence fee schedule · outpatient · +2 other terms	10	$146	$146	$4	3%	—	$140 – $156
24	Clover fee schedule · outpatient · +2 other terms	9	$140	$976	$1.2k	123%	—	$120 – $2.7k
25	Medica fee schedule · both · +3 other terms	9	$2.8k	$2.7k	$25	1%	—	$2.7k – $2.8k

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