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Gum Tissue Graft From Own Mouth, First Site

Utah 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 $389 · 10th–90th $389$3890%50%$389Professionalmedian $389 · 10th–90th $251$5370%20%10th90th$389$50.0$100.0$200.0$500.0

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
Facility
Modifier
Global
Typical Low
$389.05
Median
$389.05
Typical High
$389.05
Aetna
Setting
Professional
Modifier
Global
Typical Low
$251.19
Median
$389.05
Typical High
$478.63
Molina
Setting
Professional
Modifier
Global
Typical Low
$30.20
Median
$44.67
Typical High
$660.69
Select Health
Setting
Facility
Modifier
Global
Typical Low
$537.03
Median
$537.03
Typical High
$537.03
Select Health
Setting
Professional
Modifier
Global
Typical Low
$537.03
Median
$537.03
Typical High
$537.03
U of Utah Health Plan
Setting
Professional
Modifier
Global
Typical Low
$436.52
Median
$512.86
Typical High
$537.03