Biologic tissue matrix, per square centimeter

Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.

Model: claude-haiku-5-5
Provider: anthropic
API: message_batches
Reasoning effort: low
Max output tokens: 4096
Prompt version (hash): 444523875572
Generated: October 20, 2026

Original text from hospital filings

Xcm biologic tissue matrix, per square centimeter (add-on, list separately in addition to primary procedure)

Payers reporting HCPCS Q4142

Payer pricing summary

Low

Average

$3.1k

Median

$177

High

$70.8k

Payer rate distribution

Filter by billing methodology

Filter by billing class

#
1	UnitedHealthcare fee schedule · outpatient · +16 other terms	254	$210	$601	$2.0k	332%	—	$1 – $26.6k
2	Aetna facility · fee schedule · outpatient · +17 other terms	96	$125	$146	$166	114%	—	$87 – $2.4k
3	Blue Cross Blue Shield facility · fee schedule · outpatient · +17 other terms	83	$131	$173	$220	127%	—	$0 – $2.4k
4	Humana fee schedule · outpatient · +13 other terms	73	$125	$1.7k	$5.0k	294%	—	$1 – $20.8k
5	Cigna fee schedule · outpatient · +16 other terms	62	$134	$1.6k	$3.9k	247%	—	$33 – $21.8k
6	Molina facility · fee schedule · outpatient · +10 other terms	46	$126	$151	$231	153%	—	$65 – $2.5k
7	WellCare fee schedule · outpatient · +9 other terms	39	$135	$137	$14	10%	—	$119 – $171
8	Anthem facility · fee schedule · outpatient · +10 other terms	37	$118	$180	$167	93%	—	$48 – $1.2k
9	Ambetter facility · fee schedule · outpatient · +6 other terms	33	$212	$255	$28	11%	—	$158 – $269
10	Baylor Scott White Health Plan facility · fee schedule · outpatient · +2 other terms	25	$158	$158	$31	20%	—	$119 – $207
11	Devoted facility · fee schedule · outpatient · +6 other terms	25	$118	$123	$9	7%	—	$118 – $143
12	Kaiser fee schedule · outpatient · +6 other terms	22	$125	$307	$247	80%	—	$125 – $1000
13	Optum fee schedule · outpatient · +5 other terms	22	$125	$151	$98	65%	—	$113 – $459
14	Superior Healthplan facility · fee schedule · outpatient · +2 other terms	21	$131	$129	$3	2%	—	$125 – $131
15	Medicare fee schedule · outpatient · +4 other terms	18	$125	$125	—	—	—	$125 – $125
16	Caresource fee schedule · outpatient · +8 other terms	16	$408	$402	$202	50%	—	$1 – $524
17	Tricare fee schedule · outpatient · +2 other terms	15	$121	$119	$6	5%	—	$113 – $127
18	Medcost facility · percent of total billed charges · bothfrom % of charges	14	$46	$49	$8	17%	—	$42 – $68
19	Medical Mutual facility · fee schedule · outpatient · +4 other terms	13	$118	$119	$3	3%	—	$118 – $127
20	Oscar facility · fee schedule · outpatient · +6 other terms	11	$175	$177	$3	2%	—	$175 – $182
21	Regence fee schedule · outpatient · +6 other terms	10	$146	$146	$4	3%	—	$140 – $156
22	Magellan facility · percent of total billed charges · bothfrom % of charges	9	$39	$57	$35	62%	—	$23 – $123
23	Excellus fee schedule · outpatient · +4 other terms	6	$236	$230	$60	26%	—	$127 – $351
24	Highmark fee schedule · outpatient · +8 other terms	6	$176	$708	$979	138%	—	$127 – $3.4k
25	Medica fee schedule · both · +5 other terms	6	$139	$138	$3	2%	—	$130 – $139

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