Repair And Partial Removal Of Urethra And Urinary Opening

What the Data Says About Repair And Partial Removal Of Urethra And Urinary Opening

Across 0 states with reporting providers, CPT code 53460 (Repair And Partial Removal Of Urethra And Urinary Opening) shows a national average Medicare payment of $422.63 against an average billed charge of $2,617.86. That gap — a 6.2x markup, or 519% 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.

Urinary Surgery procedures like this one saw 31 services billed to Medicare in 2023 by 31 distinct providers, serving 29 unique beneficiaries. Regional variation is limited in the underlying CMS file. 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 Urinary Surgery category (2.24x), the estimated commercial insurance price lands near $1,219.73, with self-pay cash discounts commonly bringing the figure closer to $1,128.31. 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.