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Missouri 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
$163.36 / $200.94 / $200.94
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$146.72 / $163.36 / $200.94
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$65.42 / $159.69 / $226.39
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$163.40 / $163.40 / $163.40
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$136.11 / $200.94 / $417.96
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$1,053.42 / $1,053.42 / $1,053.42