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Wisconsin rates for HCPCS D4264

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

Facilitymedian $155 · 10th–90th $132–$3160%20%10th90th$155Professionalmedian $170 · 10th–90th $132–$4790%10%20%10th90th$170$50.0$100.0$200.0$500.0$1.0K$2.0K

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

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$131.83 / $131.83 / $131.83
Aetna
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$131.83 / $154.88 / $199.53
Anthem BCBS
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$141.25 / $257.04 / $562.34
DeanCare
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$131.83 / $162.18 / $275.42
DeanCare
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$58.88 / $58.88 / $58.88
Medica
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$131.83 / $169.82 / $275.42
Medica
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$1,047.13 / $1,047.13 / $1,047.13
Molina
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$50.12 / $58.88 / $70.79
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$234.42 / $416.87 / $575.44
Quartz
Facility/Professional
Facility
Modifier
Typical Low / Median / Typical High
$316.23 / $316.23 / $1,047.13
Quartz
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$741.31 / $1,047.13 / $1,047.13
Security Health
Facility/Professional
Professional
Modifier
Typical Low / Median / Typical High
$194.98 / $204.17 / $229.09