Medicare Rate Lookup: Highest & Lowest by State

Why does one CPT code have a highest and lowest Medicare rate within a state?

Medicare divides the country into payment localities. A state can be a single statewide locality or several. Where a state has more than one, the same code is paid a different allowed amount in each, because each locality carries its own geographic cost multipliers. The highest is the code priced in the state's most expensive locality; the lowest in its cheapest. A single-locality state pays one flat rate everywhere.

How is the Medicare allowed amount calculated?

For each locality: Allowed = (Work RVU x Work GPCI + Practice Expense RVU x PE GPCI + Malpractice RVU x MP GPCI) x Conversion Factor. The RVUs describe the work in the code and are national; the GPCIs are the local cost multipliers that differ by locality; the conversion factor is a national dollar figure that changes yearly: $33.4009 for 2026 for most clinicians. Qualifying APM Participants are paid on a slightly higher $33.5675.

How current is this data, and how often does it change?

The tool carries 17 CMS physician releases, from January 2023 to October 2026, and the date of service decides which one prices a code. CMS sets a new conversion factor every January and reissues the schedule each quarter, so a new release is added roughly every three months and the older ones never change. CMS also backdates corrections: a change request issued in April can restate a record and say the new values apply from January 1. Where that has happened the tool applies the restatement and names the change request on the result. Verify against the CMS PFS Look-Up Tool before using a figure in a report.

Can I look up Medicare rates for a past date of service, in 2023, 2024, or 2025?

Yes, and that is the point of the date field. Enter the date the service was rendered and the tool prices the code under the CMS release in force that day, with that release's own conversion factor, geographic cost indices and OPPS caps. It matters more than a year: the same code is a different number in a different quarter, so pricing a February bill under October's file misstates the benchmark. The mid-year 2024 change is simply another release, because Congress raised the conversion factor from $32.7442 to $33.2875 for dates of service on or after March 9, 2024. Litigation bills almost always carry past dates of service.

Is the hospital (facility) column what the hospital gets paid?

No. It is the doctor's fee. It is what Medicare pays the doctor when the service is done inside a hospital, and it is lower than the office figure because the hospital, not the practice, owns the room and the equipment. The hospital is paid its own amount for the same visit. That amount comes from a different Medicare schedule: the Outpatient Prospective Payment System (OPPS) for outpatient care, and an MS-DRG for an inpatient stay. This page does not show either one; our hospital outpatient and hospital inpatient lookups do. A hospital bill on a UB-04 checked against the hospital column is checked against the wrong party's money.

Look up a hospital's outpatient rate →

Is this what the provider billed, or what Medicare pays?

It is the Medicare-allowed amount, the fee-schedule benchmark, not the provider's billed charge. In bill review it serves as a defensible reference point that traces directly to the CMS source. This tool prices physician and professional services under the Physician Fee Schedule; it does not price the facility, clinical lab, DME, or anesthesia schedules. Each has its own lookup: surgery center (ASC), hospital outpatient (OPPS), hospital inpatient (MS-DRG), ambulance, and DMEPOS.

Which states have a real high-low spread?

About two-thirds of states are a single statewide Medicare locality, so they have one flat rate and no spread. The spread lives in multi-locality states. California has by far the most localities at 29, then Texas at 8, New York at 5, Illinois at 4, and Florida and Missouri at 3 each, with a run of two-locality states after that. In those states the same code can vary meaningfully between the priciest and cheapest area.

What about professional and technical components, and imaging codes?

Many imaging and diagnostic codes split into a professional component (the physician's read, modifier -26) and a technical component (the equipment and staff, modifier -TC). Enter the code with -26 or -TC to price the component instead of the global service. For certain high-cost imaging codes, Medicare caps the technical component at the lower hospital outpatient (OPPS) rate. This tool applies that cap and shows the capped Medicare-allowed amount, which can be well below the raw RVU calculation.

Where can I look up Medicare surgery center (ASC) rates?

Use the ASC fee schedule lookup. Medicare pays an ambulatory surgical center on its own schedule, separate from the physician fee schedule and from hospital outpatient payment. Enter the procedure code, the date of service and the county the center sits in. It returns the national amount and the wage-adjusted amount for that county from the CMS release in force that day, for every quarterly release back to January 2020. The surgeon's fee is a different payment, and is on this page.

Open the ASC fee schedule lookup →

What is the difference between an ASC rate and a hospital outpatient rate?

Both pay the facility for the same kind of procedure, on two different Medicare schedules. An ambulatory surgical center is paid under the ASC schedule. A hospital outpatient department is paid under OPPS, which is a different rate for the same code, adjusted by the individual hospital's own wage index. Neither one is the surgeon's fee, which is paid separately under the Physician Fee Schedule. One operation can therefore produce three Medicare figures: the surgeon, the facility, and, for anesthesia, the anesthesiologist. A bill has to be compared against the one that matches who was paid.

Compare with the hospital outpatient lookup →

How do I find what Medicare pays a specific hospital for an outpatient procedure?

Use the hospital outpatient (OPPS) payment rate lookup. Enter the procedure code, the date of service and the hospital. It returns the national OPPS rate and that hospital's own rate, because each hospital's payment is adjusted by its own wage index. Some codes are paid as part of a comprehensive package rather than alone, and the result says so beside the dollar amount. It uses the CMS quarterly release in force on the date of service, back to January 2020.

Open the hospital outpatient lookup →

How do I look up what Medicare pays a hospital for an inpatient stay (MS-DRG)?

Use the hospital inpatient (MS-DRG) payment rate lookup. Medicare pays an inpatient admission as one MS-DRG for the whole stay, not per code and not per day. Enter the MS-DRG, the discharge date and the hospital. It returns the national amount and that hospital's own, itemized stage by stage, from the CMS fiscal year in force on the discharge date. The surgeon's fee for the same admission is a separate payment on a separate claim.

Open the hospital inpatient lookup →