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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 October 2026.

How much does Gum Tissue Graft From Own Mouth, First Site cost?

$417

Typical facility fee. In Montana, October 2026.

Insurers have agreed to pay about $417 for this service. Most negotiated rates run $372 to $550.

These are rates insurers have negotiated with providers, not the amount a patient is billed. What you owe depends on your plan's deductible and coinsurance. Based on rates published by 3 insurance carriers under federal price transparency rules.

How much rates vary

Facilitymedian $417 · 10th to 90th $417 to $417Professionalmedian $398 · 10th to 90th $79 to $617
$100$200$500facility $417professional $398

Distribution of negotiated rates across all payers (price axis is log-scale). Small sample; interpret with caution. Need provider-level prices or 24+ months of history? Contact us.

Rates by insurance carrier

Insurance Carrier
Aetna
Setting
Professional
Modifier
None
Typical Low
$363.08
Median
$363.08
Typical High
$371.54
MountainHealth Co-op
Setting
Facility
Modifier
None
Typical Low
$416.87
Median
$416.87
Typical High
$416.87
Providence
Setting
Professional
Modifier
None
Typical Low
$79.43
Median
$398.11
Typical High
$616.60

Where Montana sits

The same service costs 9.5 times more in Texas than in West Virginia. Every bar is a state, most expensive first. Touch or drag across it to read any state, then open that state for its carriers and full range.

Montana· 37th of 51

$417

TX $2,399WV $251

Median negotiated rate in each state, from every insurer that publishes one. States where no insurer publishes a rate for this service are not shown.