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Ohio 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
$163.77 / $163.77 / $490.00
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$111.51 / $157.11 / $166.35
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$327.25 / $431.20 / $650.49
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$163.40 / $163.40 / $163.40
Molina
Facility/Professional
Professional
Modifier
Low / Median / High Price
$40.00 / $50.00 / $60.00