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Utah rates for HCPCS D4264

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

Facilitymedian $135 · 10th–90th $135–$1350%50%100%$135Professionalmedian $151 · 10th–90th $135–$2090%20%40%10th90th$151$50.0$100.0$200.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample — interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$134.90 / $134.90 / $134.90
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$134.90 / $151.36 / $169.82
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$30.20 / $44.67 / $162.18
Select Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$141.25 / $147.91 / $147.91
U of Utah Health Plan
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$204.17 / $218.78 / $257.04