Amnion allograft tissue, 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

American amnion ac tri-layer, per square centimeter (add-on, list separately in addition to primary procedure)

Payers reporting HCPCS Q4305

Payer pricing summary

Low

Average

$604

Median

$139

High

$11.4k

Payer rate distribution

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#
1	UnitedHealthcare fee schedule · outpatient · +7 other terms	248	$210	$211	$76	36%	—	$48 – $483
2	Aetna fee schedule · outpatient · +7 other terms	84	$127	$139	$41	30%	—	$69 – $444
3	Blue Cross Blue Shield fee schedule · outpatient · +5 other terms	84	$12.4k	$11.2k	$6.9k	61%	—	$1 – $24.5k
4	Humana fee schedule · outpatient · +5 other terms	68	$125	$126	$15	12%	—	$48 – $171
5	Cigna fee schedule · outpatient · +3 other terms	56	$126	$169	$108	64%	—	$119 – $644
6	WellCare fee schedule · outpatient · +4 other terms	40	$136	$138	$14	10%	—	$119 – $171
7	Molina facility · fee schedule · outpatient · +5 other terms	34	$118	$129	$50	39%	—	$65 – $319
8	Anthem facility · fee schedule · outpatient · +3 other terms	32	$118	$153	$91	60%	—	$48 – $349
9	Bcbs Tx fee schedule · outpatient	30	$11.0k	$11.4k	$3.6k	31%	—	$8.4k – $41.6k
10	Devoted facility · fee schedule · outpatient · +3 other terms	23	$118	$124	$11	9%	—	$118 – $143
11	Kaiser fee schedule · outpatient · +3 other terms	22	$125	$307	$247	80%	—	$125 – $1000
12	Optum fee schedule · outpatient · +1 other terms	22	$125	$151	$98	65%	—	$113 – $459
13	Ambetter fee schedule · outpatient · +2 other terms	20	$272	$267	$41	15%	—	$218 – $351
14	Medicare fee schedule · outpatient	18	$125	$125	—	—	—	$125 – $125
15	Caresource fee schedule · outpatient · +2 other terms	14	$51	$76	$56	74%	—	$48 – $199
16	Medical Mutual facility · fee schedule · outpatient · +1 other terms	12	$118	$123	$13	11%	—	$118 – $167
17	Oscar facility · fee schedule · outpatient · +1 other terms	10	$175	$177	$3	2%	—	$175 – $182
18	Regence fee schedule · outpatient · +2 other terms	10	$146	$146	$4	3%	—	$140 – $156
19	Tricare fee schedule · outpatient · +1 other terms	10	$113	$115	$4	3%	—	$113 – $121
20	Excellus fee schedule · outpatient · +2 other terms	6	$236	$230	$60	26%	—	$127 – $351
21	Highmark fee schedule · outpatient · +3 other terms	6	$176	$708	$979	138%	—	$127 – $3.4k
22	Aetna Better Health facility · fee schedule · outpatient	5	$68	$68	$1	1%	—	$68 – $70
23	Clover fee schedule · outpatient	5	$120	$125	$9	7%	—	$120 – $140
24	First Health professional · fee schedule · both	3	$122	$122	—	—	—	$122 – $122
25	Bcbs Al facility · case rate · outpatient	2	$125	$125	—	—	—	$125 – $125

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