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XCM Biologic Tissue Matrix

Montana rates for HCPCS Q4142

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

Rates data updated July 2026.

Facilitymedian $145 · 10th–90th $91$3020%10%10th90th$145Professionalmedian $117 · 10th–90th $81$1550%20%10th90th$117$100.0$200.0

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
Professional
Modifier
Global
Typical Low
$81.28
Median
$117.49
Typical High
$154.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$144.54
Typical High
$204.17
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$181.97
Providence
Setting
Facility
Modifier
Global
Typical Low
$91.20
Median
$144.54
Typical High
$302.00
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$79.43
Typical High
$125.89
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89