go back

South Dakota 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
$168.20 / $168.20 / $168.20
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.69 / $168.20 / $168.20
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$103.29 / $233.35 / $284.26
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$160.07 / $1,053.42 / $1,053.42
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$193.31 / $255.71 / $395.90
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$161.78 / $228.82 / $308.25
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$217.70 / $217.70 / $217.70