Interim caries medicament application, per tooth

Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.

Model: claude-sonnet-5-5
Provider: anthropic
API: message_batches
Reasoning effort: model default
Max output tokens: 4096
Prompt version (hash): 444523875572
Generated: October 20, 2026

Original text from hospital filings

INT CARIES MED APP PER TOOTH

Payers reporting HCPCS D1354

Payer pricing summary

Low

Average

$183

Median

$75

High

$1.4k

Payer rate distribution

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#
1	Molina facility · case rate · outpatient · +8 other terms	29	$642	$540	$477	88%	—	$74 – $1.6k
2	UnitedHealthcare professional · fee schedule · outpatient · +14 other terms	25	$114	$132	$43	33%	—	$58 – $265
3	Aetna fee schedule · outpatient · +12 other terms	21	$49	$118	$128	108%	—	$21 – $619
4	Blue Cross Blue Shield facility · fee schedule · outpatient · +8 other terms	20	$68	$80	$104	131%	—	$0 – $352
5	Anthem facility · case rate · outpatient · +7 other terms	15	$916	$1.0k	$235	23%	—	$623 – $1.6k
6	Caresource facility · case rate · outpatient · +1 other terms	15	$934	$1.0k	$230	23%	—	$623 – $1.6k
7	MultiPlan facility · percent of total billed charges · outpatientfrom % of charges · +4 other terms	13	$468	$436	$110	25%	—	$55 – $468
8	Optum facility · case rate · outpatient · +4 other terms	13	$829	$815	$369	45%	—	$82 – $1.4k
9	Cigna professional · fee schedule · outpatient · +7 other terms	10	$53	$55	$2	3%	—	$53 – $58
10	Clover facility · percent of total billed charges · outpatientfrom % of charges	10	$99	$99	—	—	—	$99 – $99
11	Highmark fee schedule · outpatient · +2 other terms	10	$4	$4	—	—	—	$4 – $4
12	Humana facility · case rate · outpatient · +9 other terms	8	$86	$89	$4	5%	—	$86 – $95
13	Aetna Better Health facility · case rate · outpatient	7	$103	$103	$1	1%	—	$99 – $103
14	Amerihealth Caritas facility · case rate · outpatient · +3 other terms	7	$95	$96	$3	3%	—	$95 – $103
15	Medicaid fee schedule · outpatient · +1 other terms	7	$72	$72	—	—	—	$72 – $72
16	Kaiser fee schedule · outpatient · +1 other terms	4	$238	$231	$157	68%	—	$72 – $523
17	Oscar professional · percent of total billed charges · outpatientfrom % of charges	4	$32	$32	—	—	—	$32 – $32
18	Medica fee schedule · outpatient · +2 other terms	3	$96	$96	—	—	—	$96 – $96
19	Wellmark facility · case rate · outpatient	3	$328	$288	$91	32%	—	$134 – $362
20	Excellus fee schedule · outpatient · +4 other terms	2	$29	$29	$27	93%	—	$7 – $63
21	Ambetter fee schedule · outpatient	1	$92	$92	—	—	—	$92 – $92
22	Bcbs Id professional · fee schedule · outpatient	1	$1	$1	—	—	—	$1 – $1
23	Bcbs Mn fee schedule · outpatient	1	$0	$0	—	—	—	$0 – $0
24	Bcbs Nv fee schedule · outpatient	1	$66	$66	$2	3%	—	$62 – $67
25	Bcbs Ny percent of total billed charges · bothfrom % of charges	1	$33	$33	—	—	—	$33 – $33

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