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Virginia 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
$157.11 / $167.10 / $167.10
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$106.69 / $157.11 / $167.10
Anthem BCBS
Facility/Professional
Professional
Modifier
Low / Median / High Price
$154.00 / $154.00 / $257.08
CareFirst
Facility/Professional
Professional
Modifier
Low / Median / High Price
$271.00 / $271.00 / $512.19
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$163.40 / $163.40 / $163.40
Kaiser Permanente
Facility/Professional
Professional
Modifier
Low / Median / High Price
$165.30 / $211.58 / $249.89
Medcost
Facility/Professional
Facility
Modifier
Low / Median / High Price
$105.17 / $167.10 / $254.49
Medcost
Facility/Professional
Professional
Modifier
Low / Median / High Price
$223.00 / $291.24 / $407.28
Sentara
Facility/Professional
Facility
Modifier
Low / Median / High Price
$71.81 / $166.78 / $9,929.00
Sentara
Facility/Professional
Professional
Modifier
Low / Median / High Price
$92.77 / $179.29 / $9,929.00