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Michigan rates for HCPCS Q4142

XCM biologic tissue matrix, per sq cm (add-on, list separately in addition to primary procedure)

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.00 / $81.00 / $81.00
BCBS
Facility/Professional
Facility
Modifier
Low / Median / High Price
$50.00 / $50.00 / $50.00
BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$47.50 / $52.00 / $67.50
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$51.50 / $51.50 / $81.00
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $55.00