Primary Listings

Average Medicare Charges for Hospital Outpatient Services, 2017

Average Medicare charges (average prices) for selected hospital outpatient services are listed here for calendar year 2017. Types of services include biopsy, breast surgery, musculoskeletal (e.g. bunions, knee cartilage, broken bone) procedures, ENT, cochlear implant, pacemaker charges, upper GI procedures, endoscopy, and more. File includes charges, what Medicare allowed, and what Medicare paid, and how many Medicare beneficiaries used that service. File shows charges to Medicare patients by physician name, state average and national average prices. Extremely difficult to use, even if somewhat familiar with using Excel files. High level price summary for about 60 categories in APC. More detail is found in the HCPCS file, a couple of thousand procedures are listed there. In 2017, this file shows that the most common type of comprehensive Observation Services in the Emergency Dept (given to over 1 million Medicare patients) had an average charge over $16,000, with Medicare allowing $2,151 on average; Medicare paid an average of $1,708. From CMS updated 2019.

Hospital Clinic and Office Visit Charges and Medicare Payments 2017

Find Hospital Clinic and Office Visit charges (average price) for 2017, and the payments that Medicare made. Find average charges for about 13,000 different codes (depending whether office or hospital facility-based).  National average prices are in the Procedure Summary file. Extremely difficult to use, even if somewhat familiar with using Excel files. File uses HCPCS codes. The most common codes were office visits 99213 (average charge about $134) and 99214 (average charge about $201). Medicare allowed about $71 for code 99213 and about $105 for 99214. Lab tests, x-ray, emergency department visits are in the file. Physician charges may be available in the Provider Summary Table. Calendar year 2017 data from CMS updated 2019.

How much does Medicare pay for the COVID-19 lab test?

How much Medicare will pay for the COVID-19 lab test is either about $36 or $51. It depends on whether the laboratory is using tests developed by the CDC, or developed its own test. Payment rates to the Medicare Administrative Contractors for claims using HCPCS code U0001 (CDC test) will get $35.91 to 35.92.  The test price for U0002 (labs performing non-CDC lab tests) is $100 for laboratories that use high-throughput technologies.  Otherwise, the outside lab receives about $51. There is no charge to the consumer for the test for the coronavirus SARS-CoV-2 under Medicare. See this fact sheet from CMS, March 12, 2020 which states the original prices. The $100 price for selected labs for U0002, U0003 or U0004 was raised from $51 to $100 effective April 14.

MN – Average Cost Per Procedure

Find the general average cost per procedure (ACP) in Minnesota for what commercial health insurance plans PAID in 2017 to medical groups. Median costs listed include Eye exams, Colonoscopy, Endoscopy with biopsy, Imaging (x-ray, CT, MRI, with and without contrast, screening mammogram, ultrasound), Lab tests (about 30 common tests), Vaccines, Mental health services and psychotherapy, Obstetric services (median $3,808 for physician services), Office Visits, Physical therapy, minor in-office surgery (e.g. skin lesion removal or vasectomy) and more. Medicare and Medicaid payment rates are also shown for reference. Minimum and maximum (range of costs) are reported for each procedure, visit or test. List of 2017 costs starts on page 10 of the 2018 Health Care Cost & Utilization Report, by Minnesota Community Measurement.

Other Helpful Listings

Fact Sheet: Underpayment by Medicare & Medicaid (2019)

Analysis by the American Hospital Association shows that Medicare and Medicaid under-pay the true cost of hospital care by about $77 billion. This cost ends up being borne by other payors and commercial insurance. Using 2017 data, it is estimated Medicare pays 87 cents on the dollar, and Medicaid also pays 87. January 2019 report

Healthcare Expenses for Seniors (MEPS)

Healthcare expenses for seniors are outlined in this MEPS report on Health Care Expenditures for the Elderly Age 65 and over. Median annual expenditures were $4,206 per person. Average annual expenses for those with expense were $9,863 in 2011. Using medical inflation rates, $9,863 was about $12,194 in 2019 dollars. Medicare paid over 62% (up considerably from 10 years earlier); private insurance paid 16%; out-of-pocket amount declined to 12%. 96% of seniors had some healthcare expense, most often office-based care and prescribed medicines. Medications took up 22% of the total, averaging $76 per purchase. For seniors, the inpatient room rate averaged $3,199 per day (sticker shock, and nearly $4,000 in 2019 dollars); ER visit was $884 on average; office visit was $228. MEPS Statistical Brief #429 uses 2011 data, published Jan. 2014.

Pennsylvania Total Hip and Knee Replacements (pdf)

2016 report shows hospital complication rates for hip & knee replacements in 2014. Statewide, the rate was 2.2% for knees and 2.8% for hip complications. The older 2015 report by PHC4 shows 2013 volume and readmission rates by hospitals in Penn. Average PA hospital charges also shown, with 2013 prices (excluding surgeon fee) at $52,912 and $55,493 for knees and hip replacements, respectively. Separately, consumers can find surgeon volume and what Medicare paid (less than 25% of the average charge) in 2012

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