| Code | Description | States | Median rate |
|---|---|---|---|
| Q4001 | Casting supplies, body cast adult, with or without head, plaster | 20 | $56.72 |
| Q4002 | Cast supplies, body cast adult, with or without head, fiberglass | 21 | $197.52 |
| Q4003 | Cast supplies, shoulder cast, adult (11 years +), plaster | 21 | $38.69 |
| Q4004 | Cast supplies, shoulder cast, adult (11 years +), fiberglass | 21 | $129.95 |
| Q4005 | Cast supplies, long arm cast, adult (11 years +), plaster | 23 | $14.27 |
| Q4006 | Cast supplies, long arm cast, adult (11 years +), fiberglass | 23 | $32.14 |
| Q4007 | Cast supplies, long arm cast, pediatric (0-10 years), plaster | 22 | $7.50 |
| Q4008 | Cast supplies, long arm cast, pediatric (0-10 years), fiberglass | 23 | $16.06 |
| Q4009 | Cast supplies, short arm cast, adult (11 years +), plaster | 23 | $9.53 |
| Q4010 | Cast supplies, short arm cast, adult (11 years +), fiberglass | 24 | $21.11 |
| Q4011 | Cast supplies, short arm cast, pediatric (0-10 years), plaster | 22 | $5.00 |
| Q4012 | Cast supplies, short arm cast, pediatric (0-10 years), fiberglass | 23 | $10.74 |
| Q4013 | Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster | 22 | $18.24 |
| Q4014 | Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), fiberglass | 23 | $29.24 |
| Q4015 | Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), plaster | 22 | $9.13 |
| Q4016 | Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), fiberglass | 23 | $14.61 |
| Q4017 | Cast supplies, long arm splint, adult (11 years +), plaster | 23 | $10.02 |
| Q4018 | Cast supplies, long arm splint, adult (11 years +), fiberglass | 23 | $15.96 |
| Q4019 | Cast supplies, long arm splint, pediatric (0-10 years), plaster | 22 | $5.27 |
| Q4020 | Cast supplies, long arm splint, pediatric (0-10 years), fiberglass | 23 | $7.78 |
| Q4021 | Cast supplies, short arm splint, adult (11 years +), plaster | 23 | $7.42 |
| Q4022 | Cast supplies, short arm splint, adult (11 years +), fiberglass | 24 | $13.20 |
| Q4023 | Cast supplies, short arm splint, pediatric (0-10 years), plaster | 22 | $3.93 |
| Q4024 | Cast supplies, short arm splint, pediatric (0-10 years), fiberglass | 23 | $6.70 |
| Q4025 | Cast supplies, hip spica (one or both legs), adult (11 years +), plaster | 21 | $41.58 |
| Q4026 | Cast supplies, hip spica (one or both legs), adult (11 years +), fiberglass | 21 | $126.00 |
| Q4027 | Cast supplies, hip spica (one or both legs), pediatric (0-10 years), plaster | 21 | $20.80 |
| Q4028 | Cast supplies, hip spica (one or both legs), pediatric (0-10 years), fiberglass | 22 | $64.01 |
| Q4029 | Cast supplies, long leg cast, adult (11 years +), plaster | 22 | $32.06 |
| Q4030 | Cast supplies, long leg cast, adult (11 years +), fiberglass | 23 | $83.74 |
| Q4031 | Cast supplies, long leg cast, pediatric (0-10 years), plaster | 23 | $15.89 |
| Q4032 | Cast supplies, long leg cast, pediatric (0-10 years), fiberglass | 22 | $44.08 |
| Q4033 | Cast supplies, long leg cylinder cast, adult (11 years +), plaster | 22 | $29.72 |
| Q4034 | Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass | 22 | $73.23 |
| Q4035 | Cast supplies, long leg cylinder cast, pediatric (0-10 years), plaster | 22 | $15.63 |
| Q4036 | Cast supplies, long leg cylinder cast, pediatric (0-10 years), fiberglass | 22 | $38.85 |
| Q4037 | Cast supplies, short leg cast, adult (11 years +), plaster | 23 | $18.08 |
| Q4038 | Cast supplies, short leg cast, adult (11 years +), fiberglass | 25 | $43.99 |
| Q4039 | Cast supplies, short leg cast, pediatric (0-10 years), plaster | 22 | $9.55 |
| Q4040 | Cast supplies, short leg cast, pediatric (0-10 years), fiberglass | 23 | $22.67 |
| Q4041 | Cast supplies, long leg splint, adult (11 years +), plaster | 22 | $23.17 |
| Q4042 | Cast supplies, long leg splint, adult (11 years +), fiberglass | 22 | $39.54 |
| Q4043 | Cast supplies, long leg splint, pediatric (0-10 years), plaster | 22 | $11.58 |
| Q4044 | Cast supplies, long leg splint, pediatric (0-10 years), fiberglass | 22 | $19.80 |
| Q4045 | Cast supplies, short leg splint, adult (11 years +), plaster | 24 | $12.59 |
| Q4046 | Cast supplies, short leg splint, adult (11 years +), fiberglass | 23 | $20.55 |
| Q4047 | Cast supplies, short leg splint, pediatric (0-10 years), plaster | 23 | $6.36 |
| Q4048 | Cast supplies, short leg splint, pediatric (0-10 years), fiberglass | 22 | $10.60 |
| Q4049 | Finger splint, static | 22 | $2.25 |
| Q4074 | Iloprost, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, up to 20 micrograms | 16 | $154.20 |
| Q4081 | Injection, epoetin alfa, 100 units (for esrd on dialysis) | 29 | $0.72 |
| Q4101 | Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) | 37 | $31.48 |
| Q4102 | Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 29 | $12.07 |
| Q4103 | Oasis burn matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 22 | $15.09 |
| Q4104 | Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) | 25 | $51.00 |
| Q4105 | Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 26 | $59.28 |
| Q4107 | Graftjacket, per square centimeter (add-on, list separately in addition to primary procedure) | 23 | $94.63 |
| Q4108 | Integra matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 22 | $58.56 |
| Q4110 | Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) | 23 | $72.27 |
| Q4111 | Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure) | 21 | $65.66 |
| Q4112 | Cymetra, injectable, 1 cc | 12 | $383.59 |
| Q4113 | Graftjacket xpress, injectable, 1 cc | 11 | $708.93 |
| Q4114 | Integra flowable wound matrix, injectable, 1 cc | 13 | $1,479.08 |
| Q4115 | Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) | 18 | $80.76 |
| Q4116 | Alloderm, per square centimeter (add-on, list separately in addition to primary procedure) | 23 | $80.76 |
| Q4117 | Hyalomatrix, per square centimeter (add-on, list separately in addition to primary procedure) | 16 | $80.76 |
| Q4118 | Matristem micromatrix, 1 mg | 10 | $2.54 |
| Q4121 | Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) | 32 | $50.33 |
| Q4122 | Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $83.49 |
| Q4123 | Alloskin rt, per square centimeter (add-on, list separately in addition to primary procedure) | 17 | $80.96 |
| Q4124 | Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 20 | $80.76 |
| Q4125 | Arthroflex, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $99.21 |
| Q4126 | Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $80.96 |
| Q4127 | Talymed, per square centimeter (add-on, list separately in addition to primary procedure) | 16 | $80.76 |
| Q4128 | Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) | 23 | $80.96 |
| Q4130 | Strattice tm, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.21 |
| Q4132 | Grafix core and grafixpl core, per square centimeter (add-on, list separately in addition to primary procedure) | 27 | $116.59 |
| Q4133 | Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) | 34 | $129.90 |
| Q4134 | Hmatrix, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $108.05 |
| Q4135 | Mediskin, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $101.16 |
| Q4136 | Ez-derm, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $101.16 |
| Q4137 | Amnioexcel, amnioexcel plus or biodexcel, per square centimeter (add-on, list separately in addition to primary procedure) | 18 | $101.71 |
| Q4138 | Biodfence dryflex, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $97.37 |
| Q4140 | Biodfence, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $103.91 |
| Q4141 | Alloskin ac, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $101.16 |
| Q4142 | Xcm biologic tissue matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $102.54 |
| Q4143 | Repriza, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $92.33 |
| Q4146 | Tensix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $102.54 |
| Q4147 | Architect, architect px, or architect fx, extracellular matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $102.54 |
| Q4148 | Neox cord 1k, neox cord rt, or clarix cord 1k, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $102.54 |
| Q4150 | Allowrap ds or dry, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $83.49 |
| Q4151 | Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) | 23 | $120.39 |
| Q4152 | Dermapure, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $81.15 |
| Q4153 | Dermavest and plurivest, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4154 | Biovance, per square centimeter (add-on, list separately in addition to primary procedure) | 19 | $106.49 |
| Q4156 | Neox 100 or clarix 100, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $82.32 |
| Q4157 | Revitalon, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4158 | Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure) | 23 | $82.32 |
| Q4159 | Affinity, per square centimeter (add-on, list separately in addition to primary procedure) | 22 | $124.11 |
| Q4160 | Nushield, per square centimeter (add-on, list separately in addition to primary procedure) | 22 | $93.93 |
| Q4161 | Bio-connekt wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4163 | Woundex, bioskin, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $108.05 |
| Q4164 | Helicoll, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $108.05 |
| Q4165 | Keramatrix or kerasorb, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4166 | Cytal, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $82.32 |
| Q4167 | Truskin, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $108.05 |
| Q4169 | Artacent wound, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4170 | Cygnus, per square centimeter (add-on, list separately in addition to primary procedure) | 17 | $93.70 |
| Q4173 | Palingen or palingen xplus, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $116.06 |
| Q4175 | Miroderm, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $87.51 |
| Q4176 | Neopatch or therion, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $82.32 |
| Q4178 | Floweramniopatch, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $87.97 |
| Q4179 | Flowerderm, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4180 | Revita, per square centimeter (add-on, list separately in addition to primary procedure) | 16 | $112.18 |
| Q4181 | Amnio wound, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.21 |
| Q4182 | Transcyte, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $82.32 |
| Q4183 | Surgigraft, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4184 | Cellesta or cellesta duo, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $83.49 |
| Q4186 | Epifix, per square centimeter (add-on, list separately in addition to primary procedure) | 37 | $151.17 |
| Q4187 | Epicord, per square centimeter (add-on, list separately in addition to primary procedure) | 24 | $169.43 |
| Q4188 | Amnioarmor, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4190 | Artacent ac, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $112.18 |
| Q4191 | Restorigin, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $116.06 |
| Q4193 | Coll-e-derm, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4194 | Novachor, per square centimeter (add-on, list separately in addition to primary procedure) | 16 | $119.93 |
| Q4195 | Puraply, per square centimeter (add-on, list separately in addition to primary procedure) | 22 | $97.94 |
| Q4196 | Puraply am, per square centimeter (add-on, list separately in addition to primary procedure) | 24 | $101.03 |
| Q4197 | Puraply xt, per square centimeter (add-on, list separately in addition to primary procedure) | 19 | $82.32 |
| Q4198 | Genesis amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4199 | Cygnus matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 17 | $111.15 |
| Q4200 | Skin te, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4201 | Matrion, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $84.26 |
| Q4203 | Derma-gide, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $119.93 |
| Q4204 | Xwrap, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $108.05 |
| Q4205 | Membrane graft or membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $112.18 |
| Q4208 | Novafix, per square cenitmeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4209 | Surgraft, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4211 | Amnion bio or axobiomembrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4214 | Cellesta cord, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4216 | Artacent cord, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4217 | Woundfix, biowound, woundfix plus, biowound plus, woundfix xplus or biowound xplus, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $112.18 |
| Q4218 | Surgicord, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4219 | Surgigraft-dual, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4220 | Bellacell hd or surederm, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4221 | Amniowrap2, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4222 | Progenamatrix, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4225 | Amniobind or dermabind tl, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4227 | Amniocore, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4229 | Cogenex amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $106.02 |
| Q4232 | Corplex, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4234 | Xcellerate, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4235 | Amniorepair or altiply, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $95.15 |
| Q4236 | Carepatch, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $112.18 |
| Q4237 | Cryo-cord, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4238 | Derm-maxx, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4239 | Amnio-maxx or amnio-maxx lite, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4247 | Amniotext patch, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $112.18 |
| Q4248 | Dermacyte amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4249 | Amniply, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4250 | Amnioamp-mp, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $103.91 |
| Q4251 | Vim, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4252 | Vendaje, per square centimeter (add-on, list separately in addition to primary procedure) | 16 | $81.15 |
| Q4253 | Zenith amniotic membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4254 | Novafix dl, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $108.05 |
| Q4255 | Reguard, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4256 | Mlg-complete, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4257 | Relese, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4258 | Enverse, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $83.49 |
| Q4259 | Celera dual layer or celera dual membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $116.06 |
| Q4260 | Signature apatch, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4261 | Tag, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4262 | Dual layer impax membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $101.47 |
| Q4263 | Surgraft tl, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $108.05 |
| Q4264 | Cocoon membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $93.70 |
| Q4265 | Neostim tl, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $108.05 |
| Q4266 | Neostim membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4267 | Neostim dl, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4268 | Surgraft ft, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $108.05 |
| Q4269 | Surgraft xt, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $103.91 |
| Q4270 | Complete sl, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $103.91 |
| Q4271 | Complete ft, per square centimeter (add-on, list separately in addition to primary procedure) | 16 | $119.93 |
| Q4272 | Esano a, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4273 | Esano aaa, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4274 | Esano ac, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $108.05 |
| Q4275 | Esano aca, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $108.05 |
| Q4276 | Orion, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $112.18 |
| Q4278 | Epieffect, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $119.93 |
| Q4279 | Vendaje ac, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $112.18 |
| Q4280 | Xcell amnio matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $112.18 |
| Q4281 | Barrera sl or barrera dl, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4282 | Cygnus dual, per square centimeter (add-on, list separately in addition to primary procedure) | 16 | $119.93 |
| Q4283 | Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $112.18 |
| Q4284 | Dermabind sl, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4285 | Nudyn dl or nudyn dl mesh, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4286 | Nudyn sl or nudyn slw, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4287 | Dermabind dl, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.56 |
| Q4288 | Dermabind ch, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.56 |
| Q4289 | Revoshield + amniotic barrier, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $108.05 |
| Q4290 | Membrane wrap-hydro, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4291 | Lamellas xt, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.56 |
| Q4292 | Lamellas, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.56 |
| Q4293 | Acesso dl, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4294 | Amnio quad-core, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4295 | Amnio tri-core amniotic, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4296 | Rebound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4297 | Emerge matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $108.05 |
| Q4298 | Amniocore pro, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $108.05 |
| Q4299 | Amniocore pro+, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4300 | Acesso tl, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $108.05 |
| Q4301 | Activate matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $108.05 |
| Q4302 | Complete aca, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $108.05 |
| Q4303 | Complete aa, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $103.91 |
| Q4304 | Grafix plus, per square centimeter (add-on, list separately in addition to primary procedure) | 15 | $112.18 |
| Q4305 | American amnion ac tri-layer, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4306 | American amnion ac, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4307 | American amnion, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4308 | Sanopellis, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4309 | Via matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $103.91 |
| Q4310 | Procenta, per 100 mg | 10 | $1,861.90 |
| Q4311 | Acesso, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4312 | Acesso ac, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4313 | Dermabind fm, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $98.42 |
| Q4314 | Reeva ft, per square cenitmeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4315 | Regenelink amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4316 | Amchoplast, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4317 | Vitograft, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4318 | E-graft, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4319 | Sanograft, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $98.42 |
| Q4320 | Pellograft, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $97.98 |
| Q4321 | Renograft, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4322 | Caregraft, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4323 | Alloply, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $98.42 |
| Q4324 | Amniotx, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4325 | Acapatch, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $98.42 |
| Q4326 | Woundplus, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $103.91 |
| Q4327 | Duoamnion, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4328 | Most, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $98.42 |
| Q4329 | Singlay, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4330 | Total, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4331 | Axolotl graft, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4332 | Axolotl dualgraft, per square centimeter (add-on, list separately in addition to primary procedure) | 14 | $103.91 |
| Q4333 | Ardeograft, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.42 |
| Q4334 | Amnioplast 1, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4335 | Amnioplast 2, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4336 | Artacent c, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4337 | Artacent trident, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4338 | Artacent velos, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4339 | Artacent vericlen, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4340 | Simpligraft, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4341 | Simplimax, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4342 | Theramend, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4343 | Dermacyte ac matrix amniotic membrane allograft, per square centimeter (add-on, list separately in addition to primary procedure) | 13 | $93.70 |
| Q4344 | Tri-membrane wrap, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4345 | Matrix hd allograft dermis, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $93.70 |
| Q4346 | Shelter dm matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $98.54 |
| Q4347 | Rampart dl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.54 |
| Q4348 | Sentry sl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.54 |
| Q4349 | Mantle dl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.54 |
| Q4350 | Palisade dm matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.54 |
| Q4351 | Enclose tl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.54 |
| Q4352 | Overlay sl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $98.54 |
| Q4353 | Xceed tl matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $103.91 |
| Q4354 | Palingen dual-layer membrane and dual-layer palingen x-membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4355 | Abiomend xplus membrane and abiomend xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4356 | Abiomend membrane and abiomend hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4357 | Xwrap plus, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.56 |
| Q4358 | Xwrap dual, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4359 | Choriply, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4360 | Amchoplast fd, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4361 | Epixpress, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.56 |
| Q4362 | Cygnus disk, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4363 | Amnio burgeon membrane and hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4364 | Amnio burgeon xplus membrane and xplus hydromembrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4365 | Amnio burgeon dual-layer membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4366 | Dual layer amnio burgeon x-membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4367 | Amniocore sl, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $99.56 |
| Q4368 | Amchothick, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4369 | Amnioplast 3, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4370 | Aeroguard, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4371 | Neoguard, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4372 | Amchoplast excel, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4373 | Membrane wrap lite, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4375 | Duograft ac, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4376 | Duograft aa, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4377 | Trigraft ft, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4378 | Renew ft matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4379 | Amniodefend ft matrix, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4380 | Advograft one, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4382 | Advograft dual, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $95.20 |
| Q4383 | Axolotl graft ultra, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4384 | Axolotl dualgraft ultra, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4385 | Apollo ft, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4386 | Acesso trifaca, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4387 | Neothelium ft, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4388 | Neothelium 4l, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4389 | Neothelium 4l+, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4390 | Ascendion, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $97.87 |
| Q4391 | Amnioplast double, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4392 | Grafix duo, per square centimeter (add-on, list separately in addition to primary procedure) | 12 | $97.87 |
| Q4393 | Surgraft ac, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4394 | Surgraft aca, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4395 | Acelagraft, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4396 | Natalin, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4397 | Summit aaa, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4398 | Summit ac, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4399 | Summit fx, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4400 | Polygon3 membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4401 | Absolv3 membrane, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4402 | Xwrap 2.0, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4403 | Xwrap dual plus, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4404 | Xwrap hydro plus, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4405 | Xwrap fenestra plus, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4406 | Xwrap fenestra, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4407 | Xwrap tribus, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4408 | Xwrap hydro, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4409 | Amniomatrixf3x, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4410 | Amchomatrixdl, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4411 | Amniomatrixf4x, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4412 | Choriofix, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4413 | Cygnus solo, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4414 | Simplichor, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4415 | Alexiguard sl-t, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4416 | Alexiguard tl-t, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4417 | Alexiguard dl-t, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
| Q4420 | Nuform, per square centimeter (add-on, list separately in addition to primary procedure) | 11 | $91.83 |
Published Medicaid fee-for-service schedule amounts, not a coverage or eligibility guarantee. Managed-care plan rates can differ. Where no prior-authorization flag is shown, the state does not publish one. Descriptions are ProviderSignal's own plain-language labels or public-domain CMS text.