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GRAFTJACKET

Pennsylvania rates for HCPCS Q4107

GRAFTJACKET, per sq cm (add-on, list separately in addition to primary procedure)

Rates data updated July 2026.

Facilitymedian $107 · 10th–90th $85$4680%20%40%10th90th$107Professionalmedian $85 · 10th–90th $81$1260%50%10th90th$85$100.0$500.0$2.0K$10.0K$50.0K

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$85.11
Median
$85.11
Typical High
$144.54
Aetna
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$85.11
Typical High
$85.11
Capital Blue Cross
Setting
Facility
Modifier
Global
Typical Low
$109.65
Median
$128.82
Typical High
$8,511.38
Capital Blue Cross
Setting
Professional
Modifier
Global
Typical Low
$128.82
Median
$128.82
Typical High
$128.82
Cigna
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$446.68
Typical High
$478.63
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Emblem Health
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$100.00
Typical High
$147.91
Geisinger
Setting
Professional
Modifier
Global
Typical Low
$89.13
Median
$144.54
Typical High
$204.17
Highmark BCBS
Setting
Facility
Modifier
Global
Typical Low
$2,041.74
Median
$2,041.74
Typical High
$2,041.74
Martin's Point
Setting
Facility
Modifier
Global
Typical Low
$85.11
Median
$85.11
Typical High
$144.54
Martin's Point
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$85.11
Typical High
$85.11
UPMC Health Plan
Setting
Facility
Modifier
Global
Typical Low
$107.15
Median
$316.23
Typical High
$398.11
United
Setting
Facility
Modifier
Global
Typical Low
$154.88
Median
$154.88
Typical High
$154.88
United
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$125.89
Typical High
$141.25