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.
Original text from hospital filings
Polygon3 membrane, per square centimeter (add-on, list separately in addition to primary procedure)
Low
$109
Average
$118
Median
$121
High
$121
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4 hospital rates
iThe hospitals that file a Tricare rate for this code, one row per hospital and set of terms (billing class, payment method, setting). Rates under different terms are never blended, so the terms are shown under each hospital’s name. Figures are the hospital’s averages across its plans.| # | Plans | |||||||
|---|---|---|---|---|---|---|---|---|
| 1 | Canton-Potsdam Hospital Potsdam, NY facility · fee schedule · outpatient | 1 | $109 | $109 | — | — | — | $109 – $109 |
| 2 | NATIONWIDE CHILDREN'S HOSPITAL TOLEDO, LLC Toledo, OH facility · fee schedule · outpatient | 1 | $121 | $121 | — | — | — | $121 – $121 |
| 3 | Nationwide Children's Hospital Columbus, OH facility · fee schedule · outpatient | 1 | $121 | $121 | — | — | — | $121 – $121 |
| 4 | Newark-Wayne Community Hospital Newark, NY facility · fee schedule · outpatient | 1 | $121 | $121 | — | — | — | $121 – $121 |
← Payers reporting HCPCS Q4400 · Snapshot 20261113T090226Z-3ce6c0b8