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Montana rates for HCPCS D4264

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

Facilitymedian $302 · 10th–90th $229–$3470%50%10th90th$302Professionalmedian $155 · 10th–90th $135–$3020%20%10th90th$155$100.0$200.0$500.0$1.0K$2.0K$5.0K

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
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$134.90 / $154.88 / $194.98
MountainHealth Co-op
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$302.00 / $302.00 / $4,570.88
MountainHealth Co-op
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$302.00 / $302.00 / $4,570.88
Providence
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$107.15 / $229.09 / $295.12
Providence
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$79.43 / $85.11 / $338.84