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GRAFTJACKET

Washington rates for HCPCS Q4107

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

Rates data updated July 2026.

Facilitymedian $162 · 10th–90th $87$3470%10%10th90th$162Professionalmedian $85 · 10th–90th $81$1510%50%10th90th$85$50.0$100.0$200.0$500.0$1.0K

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
$269.15
Typical High
$309.03
Aetna
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$83.18
Typical High
$87.10
Asuris Northwest Health
Setting
Facility
Modifier
Global
Typical Low
$112.20
Median
$125.89
Typical High
$125.89
Asuris Northwest Health
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$141.25
Cigna
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$169.82
Typical High
$251.19
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Kaiser Permanente
Setting
Facility
Modifier
Global
Typical Low
$104.71
Median
$177.83
Typical High
$380.19
Kaiser Permanente
Setting
Professional
Modifier
Global
Typical Low
$95.50
Median
$165.96
Typical High
$218.78
Molina
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$33.11
Typical High
$93.33
Pacific Source
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$144.54
Typical High
$144.54
Premera BCBS
Setting
Facility
Modifier
Global
Typical Low
$83.18
Median
$85.11
Typical High
$125.89
Premera BCBS
Setting
Professional
Modifier
Global
Typical Low
$85.11
Median
$85.11
Typical High
$85.11
Regence BlueShield
Setting
Facility
Modifier
Global
Typical Low
$100.00
Median
$112.20
Typical High
$125.89
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$141.25
United
Setting
Facility
Modifier
Global
Typical Low
$102.33
Median
$102.33
Typical High
$208.93
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Wellpoint
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$154.88
Typical High
$295.12