Simple Repair Of Salivary Duct
Price Range Across States
What You Might Pay
Estimated using RAND 2024 commercial-to-Medicare ratios. Actual prices vary by insurer, plan, and facility.
How we estimate these prices
These estimates are based on the RAND Hospital Price Transparency Study (4th Edition, 2024), which found that commercial insurance prices average 224% of Medicare rates nationally. We apply category-specific ratios: Digestive Surgery procedures average 2.24x Medicare rates. Cash/self-pay estimates blend typical cash discounts (55% of billed charges) with Medicare-based estimates (150% of allowed amounts). These are statistical estimates, not quotes. Contact your insurer or provider for actual costs.
Prices by State
| State | Medicare Payment | Billed Charge |
|---|---|---|
| California | $409.79 | $1,783.41 |
| Pennsylvania | $365.82 | $2,224.66 |
| New York | $250.67 | $2,000.76 |
What the Data Says About Simple Repair Of Salivary Duct
Across 3 states with reporting providers, CPT code 42500 (Simple Repair Of Salivary Duct) shows a national average Medicare payment of $420.31 against an average billed charge of $2,013.54. That gap — a 4.8x markup, or 379% above the Medicare allowed amount — reflects chargemaster pricing, not what most insured patients actually pay. Medicare's negotiated rate is the statutory benchmark; commercial insurers typically settle between the two figures based on network contracts.
Digestive Surgery procedures like this one saw 264 services billed to Medicare in 2023 by 214 distinct providers, serving 230 unique beneficiaries. State-level variation is significant: New York reports the lowest average payment at $250.67, while California reports the highest at $409.79. Geographic Practice Cost Indices (GPCIs) explain much of that spread — local malpractice premiums, practice expense, and physician work adjustments all shift the allowed amount even when the procedure is identical.
Applying RAND 2024 commercial-to-Medicare ratios specific to the Digestive Surgery category (2.24x), the estimated commercial insurance price lands near $1,189.20, with self-pay cash discounts commonly bringing the figure closer to $951.89. Uninsured patients facing the full billed charge have the strongest leverage to negotiate — the Hospital Price Transparency Rule (effective January 2021) requires providers to publish standard charges, cash rates, and payer-specific negotiated prices. This data is for educational reference; confirm coverage and out-of-pocket exposure with your insurer before any procedure.
Frequently Asked Questions
How much does Simple Repair Of Salivary Duct cost?
The national average Medicare payment for Simple Repair Of Salivary Duct (CPT 42500) is $420.31, while providers typically bill $2,013.54. Prices vary significantly by state, ranging from $250.67 to $409.79.
Why do providers charge more than Medicare pays?
Providers set their own chargemaster rates (billed charges), which are typically much higher than what any insurer pays. Medicare pays a fixed rate based on the procedure code and geographic location. The billed charge is relevant mainly for uninsured patients, who may face prices closer to the submitted charge.
How much does Simple Repair Of Salivary Duct cost with insurance?
With commercial insurance, Simple Repair Of Salivary Duct costs an estimated $1,189.20 on average (range: $832.44 – $1,664.88). Without insurance, the estimated cash price is $951.89. These estimates are based on RAND 2024 research on commercial-to-Medicare price ratios. Your actual cost depends on your insurer, plan, and provider.
Which state has the lowest cost for Simple Repair Of Salivary Duct?
New York has the lowest average Medicare payment for Simple Repair Of Salivary Duct at $250.67, while California has the highest at $409.79. This $159.12 difference reflects geographic variation in healthcare costs, local cost of living, and provider market dynamics.
How many providers perform Simple Repair Of Salivary Duct?
Nationally, 214 providers billed Medicare for Simple Repair Of Salivary Duct in 2023, performing 264 total services for 230 beneficiaries across 3 states and territories.
What is the billed-to-Medicare markup for Simple Repair Of Salivary Duct?
Providers bill 4.8x what Medicare pays for Simple Repair Of Salivary Duct — a 379% markup. This gap between billed charges and actual payment is common across healthcare. Uninsured patients may face charges closer to the billed amount, while insured patients pay negotiated rates between the Medicare and billed figures.
Related Guides
Tips to reduce out-of-pocket costs
Your right to upfront pricing
How Medicare payments work
Decode charges and codes
Why bills exceed actual costs
Geographic pricing factors
Related Data Sources
Data from CMS Medicare Physician & Other Practitioners (2023).
Read our methodology — how this data is sourced, computed, and verified.