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XCM Biologic Tissue Matrix

Utah 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 $100 · 10th–90th $100$1200%50%90th$100Professionalmedian $126 · 10th–90th $100$1550%50%10th90th$126$50.0$200.0$1.0K$5.0K$20.0K

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
Facility
Modifier
Global
Typical Low
$100.00
Median
$100.00
Typical High
$100.00
Aetna
Setting
Professional
Modifier
Global
Typical Low
$100.00
Median
$125.89
Typical High
$154.88
Cigna
Setting
Facility
Modifier
Global
Typical Low
$144.54
Median
$144.54
Typical High
$446.68
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$44.67
Typical High
$75.86
Regence BlueShield
Setting
Professional
Modifier
Global
Typical Low
$123.03
Median
$141.25
Typical High
$162.18
Select Health
Setting
Facility
Modifier
Global
Typical Low
$120.23
Median
$120.23
Typical High
$120.23
Select Health
Setting
Professional
Modifier
Global
Typical Low
$117.49
Median
$120.23
Typical High
$154.88
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$83.18
Median
$169.82
Typical High
$269.15
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$125.89