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South Carolina 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
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$105.30 / $105.30 / $105.30
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $30.00