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New Mexico 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
$133.77 / $133.77 / $133.77
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$133.77 / $146.19 / $152.94
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$45.00 / $70.00 / $1,500.00
Providence
Facility/Professional
Facility
Modifier
Low / Median / High Price
$77.98 / $121.53 / $171.42
Providence
Facility/Professional
Professional
Modifier
Low / Median / High Price
$2,400,000.00 / $2,400,000.00 / $2,400,000.00