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Michigan rates for HCPCS D4264

Bone Replacement Graft - Retained Natural Tooth - Each Additional Site In Quadrant

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$155.66 / $155.66 / $155.66
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$137.09 / $155.66 / $163.77
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$163.40 / $163.40 / $177.09
Health Alliance Plan
Facility/Professional
Facility
Modifier
Low / Median / High Price
$155.66 / $155.66 / $155.66
Health Alliance Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$140.44 / $155.66 / $163.22
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$30.00 / $30.00 / $55.00