Methodology & Data Sources

Primary Data Source

All data comes from the CMS Medicare Physician & Other Practitioners dataset (2023), published by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. This dataset contains aggregate statistics by provider and procedure for all Medicare Part B services billed in 2023. It includes over 9,000 CPT/HCPCS procedure codes billed across 162,808 individual providers.

What We Track

• 9,297 procedures: Every CPT/HCPCS code billed to Medicare, with national and state-level pricing statistics.
• 5,426 hospitals: CMS Hospital Compare data including quality ratings, bed counts, and emergency service availability.
• 162,808 providers: Individual Medicare providers with their procedure volumes and charge/payment data.
• 198,292 state-level price records: Geographic variation in procedure costs across 56 states and territories.

Processing Pipeline

We download the CMS Medicare Physician and Other Practitioners dataset and process each CPT/HCPCS code to extract national and state-level pricing. For every procedure, we calculate:

• National average Medicare payment amount (what Medicare actually pays providers)
• National average submitted charge (what providers bill — their "chargemaster" rate)
• Markup ratio: submitted charge ÷ Medicare payment
• State-level variation: average Medicare payment and submitted charge by state

No data is modified, interpolated, or editorialized. Medicare payment amounts reflect the actual average amounts paid by Medicare for each procedure at each provider.

Understanding the Numbers

• Medicare Payment: What Medicare actually reimburses the provider. This is a standardized rate based on the procedure code and a geographic adjustment factor (GPCI). Private insurers often pay similar but not identical amounts.
• Submitted Charge: The provider's list price ("chargemaster" rate). This is typically far higher than what any payer actually pays. Uninsured patients may receive bills closer to this amount before any financial assistance is applied.
• Markup: Submitted charge ÷ Medicare payment. A 4.0x markup means the provider's list price is 4 times what Medicare pays.

Data Collection Method

CMS collects Medicare claims data from all Medicare-certified providers who bill under fee-for-service Part B. Each claim includes the procedure code (CPT/HCPCS), the amount billed by the provider, the amount Medicare paid, the provider's NPI, and the geographic location. CMS aggregates these individual claims into annual summary files that report average charges and payments by provider and procedure code, suppressing any provider-procedure combination with fewer than 11 beneficiaries to protect patient privacy.

Update Schedule

CMS publishes the Medicare Physician and Other Practitioners dataset annually, typically 12–18 months after the reference calendar year. We update our database when each new annual release becomes available. Between updates, the most recent published year's data is displayed. Medicare payment rates are adjusted annually through the Physician Fee Schedule rulemaking process, so year-over-year comparisons reflect both utilization changes and rate adjustments.

Limitations

• Data covers Medicare fee-for-service claims only. Commercial insurance rates are not disclosed publicly.
• Procedure codes describe services, not outcomes. A surgeon billing the same CPT code as a high-volume procedure center may provide very different service quality.
• State-level averages mask significant variation within states (urban vs. rural, academic vs. community settings).
• CMS releases updated data annually; prices change year to year based on Medicare rate adjustments.
• Provider-procedure combinations with fewer than 11 beneficiaries are suppressed by CMS for privacy, which may exclude some low-volume specialists.
• Submitted charges (chargemaster rates) are set by each provider and do not reflect what any payer actually reimburses.

Editorial Workflow

Content on PlainProcedure is compiled by our editorial team. Raw data from the CMS Medicare Physician & Other Practitioners dataset and CMS Hospital Compare is ingested programmatically by our ETL pipeline; CPT/HCPCS code descriptions, narrative framing, guide text, rankings commentary, and methodology writeups are drafted by our editorial team and then reviewed line-by-line by the PlainProcedure Editorial team at Kiznis Studio before publication. We follow rigorous editorial standards: source data is loaded directly from official agencies, never invented or interpolated. No page on PlainProcedure is published without human review. This site is for informational purposes only and does not provide medical advice — always consult a licensed physician for clinical decisions. We do not accept payment for coverage, placement, or rankings — markup and cost figures are computed directly from CMS-published Medicare payment data.

Not Affiliated

PlainProcedure is not affiliated with CMS, Medicare, or any government agency. This site is for informational purposes only and does not provide medical or financial advice.

Frequently Asked Questions