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XCM Biologic Tissue Matrix

South Dakota 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 $138 · 10th–90th $81$2450%20%10th90th$138Professionalmedian $126 · 10th–90th $81$1820%20%10th90th$126$50.0$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. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Aetna
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$117.49
Typical High
$131.83
Cigna
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$194.98
Typical High
$245.47
Cigna
Setting
Professional
Modifier
Global
Typical Low
$147.91
Median
$147.91
Typical High
$181.97
Medica
Setting
Facility
Modifier
Global
Typical Low
$46.77
Median
$114.82
Typical High
$162.18
Midlands
Setting
Facility
Modifier
Global
Typical Low
$169.82
Median
$169.82
Typical High
$204.17
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$263.03