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

Amnio burgeon dual-layer membrane, per square centimeter (add-on, list separately in addition to primary procedure)

Payers reporting HCPCS Q4365

Payer pricing summary

Low

$68

Average

$400

Median

$133

High

$3.4k

Payer rate distribution

Filter by billing methodology

Filter by billing class

#
1	UnitedHealthcare fee schedule · outpatient · +7 other terms	246	$210	$221	$219	99%	—	$51 – $4.7k
2	Aetna fee schedule · outpatient · +7 other terms	85	$127	$139	$41	30%	—	$69 – $444
3	Blue Cross Blue Shield fee schedule · outpatient · +4 other terms	84	$9	$33	$47	144%	—	$1 – $170
4	Humana fee schedule · outpatient · +5 other terms	67	$125	$127	$13	10%	—	$116 – $171
5	Cigna fee schedule · outpatient · +4 other terms	57	$128	$252	$910	361%	—	$119 – $10.2k
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 fee schedule · outpatient · +4 other terms	23	$155	$294	$305	103%	—	$123 – $911
9	Devoted facility · fee schedule · outpatient · +3 other terms	23	$118	$124	$11	9%	—	$118 – $143
10	Kaiser fee schedule · outpatient · +3 other terms	22	$125	$307	$247	80%	—	$125 – $1000
11	Optum fee schedule · outpatient · +1 other terms	22	$125	$151	$98	65%	—	$113 – $459
12	Ambetter fee schedule · outpatient · +2 other terms	20	$272	$267	$41	15%	—	$218 – $351
13	Medicare fee schedule · outpatient	18	$125	$125	—	—	—	$125 – $125
14	Caresource facility · fee schedule · outpatient · +2 other terms	14	$212	$180	$42	23%	—	$121 – $238
15	Medical Mutual facility · fee schedule · outpatient · +1 other terms	12	$118	$123	$13	11%	—	$118 – $167
16	Oscar facility · fee schedule · outpatient · +1 other terms	10	$175	$177	$3	2%	—	$175 – $182
17	Regence fee schedule · outpatient · +4 other terms	10	$146	$146	$4	3%	—	$140 – $156
18	Tricare fee schedule · outpatient · +1 other terms	10	$113	$115	$4	3%	—	$113 – $121
19	Excellus fee schedule · outpatient · +2 other terms	6	$236	$230	$60	26%	—	$127 – $351
20	Highmark fee schedule · outpatient · +3 other terms	6	$176	$1.9k	$2.1k	112%	—	$127 – $5.3k
21	Aetna Better Health facility · fee schedule · outpatient	5	$68	$68	$1	1%	—	$68 – $70
22	Clover fee schedule · outpatient	5	$120	$125	$9	7%	—	$120 – $140
23	First Health professional · fee schedule · both	3	$122	$122	—	—	—	$122 – $122
24	Bcbs Al facility · case rate · outpatient	2	$125	$125	—	—	—	$125 – $125
25	Bcbs Id fee schedule · outpatient	2	$140	$140	—	—	—	$140 – $140

Page 1 of 2 · 37 payers