Methodology

Data source

Exact source

Price information comes from the CMS Medicare Physician & Other Practitioners provider-and-service release published in 2026, covering services delivered in calendar year 2024.

The source is organized by National Provider Identifier, HCPCS code, place of service, service volume, submitted charges, Medicare-approved amounts, and Medicare payment amounts. It does not include a claim-modifier field that identifies professional, technical, or global component billing.

The March 2025 CMS methodology for this release says that a facility-place-of-service record in this dataset generally represents the physician professional fee and does not include the facility payment. Ambulatory surgical centers are the documented exception: both the physician professional fee and the ASC facility fee are represented. MedCostCompare therefore labels a direct organization-NPI amount as an ASC facility amount only when the CMS provider type is exactly “Ambulatory Surgical Center.” Other organization records do not receive a facility-amount label.

Dataset limitations

What the source cannot establish

• Original Medicare only: the file covers Medicare Part B fee-for-service claims. It excludes Medicare Advantage claims and does not describe a provider's privately insured, other-program, or uninsured patients, so it may represent only part of a practice.
• Privacy suppression: CMS excludes provider-service records derived from 10 or fewer beneficiaries. Totals calculated from the public file can therefore understate actual Medicare fee-for-service activity.
• No quality measure: the file reports utilization and payment information, not care quality. Service volume, price, or position in a table does not establish experience, outcomes, or a recommendation.
• Amounts vary for reasons the file does not fully expose: modifiers, geography, multiple services on the same day, and other claim details can affect allowed amounts. This extract does not include the modifier field needed to resolve every professional, technical, or global billing mode.
• No risk adjustment: the provider-and-service rows do not adjust for differences in patient illness severity or case mix.
• Individual and organization billing can overlap: when services are billed under both individual and organization NPIs, the public file does not identify the individual's share of the organization total. MedCostCompare keeps those evidence types separate rather than claiming a combined provider total.

Data year

Date range used

This site build uses the report's calendar year 2024 provider-service records. Calendar year 2024 is the service year represented by the displayed procedure-amount calculations.

Procedure grouping

How procedures are grouped

Each public procedure page starts with a manually confirmed procedure concept, such as colonoscopy or cataract surgery. A concept may contain one or more subtypes when closely related services should be shown separately.

Procedure pages are built only from codes that have been explicitly included in the local project database. Related codes stay grouped until manual review decides that they should be split into separate subtypes.

CPT and HCPCS

Billing code logic

MedCostCompare uses the HCPCS code field in the CMS provider-service report. Many procedures on the site are identified by CPT codes that appear in the CMS data as HCPCS codes.

Included codes must match the user-facing procedure. Codes are not added to a published procedure page only because they share a keyword or sound related; they must be part of a confirmed procedure definition.

Inclusion rules

What gets included or excluded

Provider rankings use CMS records for individual clinicians only. Organization records are not mixed into the provider price distribution. For the confirmed code set in a metro area, MedCostCompare totals clinician service volume by CMS place of service and selects the setting with the most services: facility or non-facility. Records from every other setting are excluded from that comparison.

Within each separately defined procedure subtype, records are combined by National Provider Identifier. A provider must have at least 30 qualifying services in the selected setting. After that volume filter, a CMS provider type is included only when it represents at least 10% of qualifying services and contains at least two providers.

Before the numeric gates are applied, each subtype must also pass a component-mode review. Services that may mix professional, technical, and global prices remain suppressed unless the source and method can distinguish those modes. Exact code and care setting alone do not satisfy this review when modifier detail is absent.

A local comparison is published only when the final cohort contains at least 10 providers and at least 500 qualifying local services, and the 75th-percentile Medicare-approved amount divided by the 25th-percentile amount is at least 1.25. The component review and all three numeric gates must pass; if the percentile ratio cannot be calculated, the subtype does not qualify.

Pages that do not produce at least one valid local comparison section are suppressed from publish output. This prevents limited or misleading local rows from appearing as consumer-facing price rankings.

Provider medians and ranges

How provider amount summaries are calculated

The price shown for a provider is based on the CMS average Medicare-approved amount for the included code or codes, weighted by that provider's service volume when multiple rows are combined.

The procedure-subtype summary is the median of those included provider-level amounts in that metro area and selected care setting. Each included provider contributes one amount to the distribution. The displayed middle-half range is the 25th to 75th percentile of the same provider-level amounts.

Price variation is measured as the 75th-percentile amount divided by the 25th-percentile amount. A subtype must have a p75/p25 ratio of at least 1.25, in addition to the provider and service-volume gates above, before MedCostCompare displays a provider comparison.

Outliers

How unusual rows are handled

MedCostCompare reduces noisy comparisons by requiring minimum provider volume, minimum metro service volume, clinician-only rankings, confirmed code sets, and publish thresholds. Provider price summaries use medians and percentile ranges rather than simple averages, which reduces the influence of extreme values.

The site does not manually edit individual provider prices. If a procedure-metro combination produces implausible or unstable local results, it should be suppressed until the procedure logic or setting logic is reviewed.

Refresh cadence

How often data is refreshed

CMS updates this public data annually. MedCostCompare expects to refresh procedure calculations after new CMS provider-service data is available and after the procedure definitions and publish thresholds are reviewed.

Caveats

Medicare, private insurance, and out-of-pocket costs

Medicare-approved amounts are not the same as private insurance allowed amounts, billed charges, cash-pay prices, or a patient's final out-of-pocket cost. Your actual cost can depend on insurance plan rules, deductible status, coinsurance, provider network status, facility fees, anesthesia, imaging, pathology, complications, and other services billed around the procedure.

Use MedCostCompare as a directional public-data comparison. Read why facility and professional fees may be separate, then use the complete-estimate checklist before scheduled care.