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Pennsylvania 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
Capital Blue Cross
Facility/Professional
Facility
Modifier
Low / Median / High Price
$967.00 / $967.00 / $967.00
Emblem Health
Facility/Professional
Professional
Modifier
Low / Median / High Price
$25.00 / $25.00 / $25.00
Martin's Point
Facility/Professional
Professional
Modifier
Low / Median / High Price
$81.00 / $81.00 / $81.00