Q4400, Polygon3 membrane, per square centimeter (add-on, list separately in addition
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$127.26
Non-Facility
$127.26
2 Active Policies
EVICORE-HPLAN-CIGNA-1815296EE67F, Cigna Comprehensive Code List - Effective 03/07/2026
EVICORE-HPLAN-CIGNA-57D571603CB4, Cigna Commercial Other Services Code List - Effective 03/07/2026
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.