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Montana rates for HCPCS D4264

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

Insurance Carrier
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.96 / $161.96 / $162.18
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$88.39 / $200.94 / $259.33
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$162.40 / $250.31 / $1,800,000.00