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Gum Tissue Graft From Own Mouth, First Site

Montana rates for HCPCS D4273

A dental procedure that takes a small piece of the patient's own tissue and grafts it onto the gums at a tooth, implant, or toothless position. This charge covers the first site treated and includes the work at both the donor and recipient areas.

Rates data updated July 2026.

Facilitymedian $646 · 10th–90th $537$4,5710%50%10th90th$646Professionalmedian $631 · 10th–90th $372$7410%20%10th90th$631$100.0$200.0$500.0$1.0K$2.0K$5.0K

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
Setting
Professional
Modifier
Global
Typical Low
$371.54
Median
$371.54
Typical High
$371.54
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$630.96
Median
$645.65
Typical High
$4,570.88
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$630.96
Median
$645.65
Typical High
$4,570.88
Providence
Setting
Facility
Modifier
Global
Typical Low
$309.03
Median
$478.63
Typical High
$660.69
Providence
Setting
Professional
Modifier
Global
Typical Low
$79.43
Median
$85.11
Typical High
$794.33