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XCM Biologic Tissue Matrix

Wisconsin 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 $398 · 10th–90th $123$7080%20%10th90th$398Professionalmedian $135 · 10th–90th $115$3720%20%10th90th$135$5.0$20.0$100.0$500.0$2.0K

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
$123.03
Median
$123.03
Typical High
$123.03
Aetna
Setting
Professional
Modifier
Global
Typical Low
$81.28
Median
$123.03
Typical High
$131.83
Anthem BCBS
Setting
Professional
Modifier
Global
Typical Low
$151.36
Median
$257.04
Typical High
$467.74
Cigna
Setting
Facility
Modifier
Global
Typical Low
$199.53
Median
$398.11
Typical High
$602.56
Cigna
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$131.83
Typical High
$181.97
Medica
Setting
Facility
Modifier
Global
Typical Low
$100.00
Median
$100.00
Typical High
$100.00
Molina
Setting
Professional
Modifier
Global
Typical Low
$32.36
Median
$50.12
Typical High
$70.79
Quartz
Setting
Professional
Modifier
Global
Typical Low
$141.25
Median
$302.00
Typical High
$416.87
Quartz
Setting
Facility
Modifier
Global
Typical Low
$389.05
Median
$489.78
Typical High
$707.95
Quartz
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$660.69
Security Health
Setting
Professional
Modifier
Global
Typical Low
$147.91
Median
$147.91
Typical High
$147.91
Security Health
Setting
Professional
Modifier
Global
Typical Low
$147.91
Median
$190.55
Typical High
$338.84
United
Setting
Facility
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$295.12
United
Setting
Professional
Modifier
Global
Typical Low
$125.89
Median
$125.89
Typical High
$144.54