Estimate Medicare costs by selecting procedures. Costs shown are average Medicare payments based on 2023 data.
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Medicare doesn't pay whatever a provider charges. Instead, it uses the Medicare Physician Fee Schedule (MPFS), which sets an "allowed amount" for each procedure code based on three factors: the work involved (physician time and skill), practice expense (rent, staff, equipment), and malpractice insurance costs.
These components are adjusted by a Geographic Practice Cost Index (GPCI) that accounts for regional cost-of-living differences. A procedure in Manhattan costs Medicare more than the same procedure in rural Iowa because rent, staff wages, and malpractice premiums are higher.
Medicare typically pays 80% of the allowed amount. The beneficiary is responsible for the remaining 20% coinsurance (unless they have supplemental insurance). Providers who "accept assignment" agree to take the Medicare-approved amount as full payment. Those who don't can charge up to 15% more (the "limiting charge").
| Procedure | Code | Avg Medicare Payment | Typical Charge |
|---|---|---|---|
| Office Visit (Established Patient, Moderate) | 99214 | ~$110 | ~$250 |
| Office Visit (New Patient, Moderate) | 99203 | ~$110 | ~$300 |
| Eye Injection (Aflibercept/Eylea) | J0178 | ~$1,850 | ~$2,200 |
| Chest X-Ray (2 Views) | 71046 | ~$25 | ~$150 |
| Complete Blood Count (CBC) | 85025 | ~$8 | ~$35 |
| MRI Brain Without Contrast | 70551 | ~$240 | ~$2,500 |
| Colonoscopy with Biopsy | 45380 | ~$350 | ~$2,000 |
| Physical Therapy Evaluation | 97163 | ~$95 | ~$200 |
⚠️ Typical charges show what providers submit; Medicare pays substantially less. The gap between charges and payments is the "markup" analyzed in our Markup Analysis.
Most beneficiaries pay $185/month for Part B in 2026. Higher earners pay more through Income-Related Monthly Adjustment Amounts (IRMAA).
You pay the first $257 per year (2026) before Medicare starts paying its share. After that, you typically pay 20% coinsurance.
Starting in 2025, Part D out-of-pocket costs are capped at $2,000/year. Combined with IRA-negotiated drug prices in 2026, many beneficiaries are seeing significant savings.
Providers who accept assignment agree to Medicare's approved amount. Non-participating providers can charge up to 15% more. Always ask before your visit.
Use our Provider Compare tool to see how different doctors in your area charge for the same procedures.
Providers who accept assignment can't charge you more than the Medicare-approved amount. This can save you hundreds per visit.
Medicare Supplement (Medigap) policies can cover your 20% coinsurance, deductibles, and excess charges — making your out-of-pocket costs more predictable.
With the new $2,000 annual cap on Part D out-of-pocket spending and IRA-negotiated prices, check if your medications are among the drugs with reduced costs in 2026.
Medicare generally pays lower rates than private insurance for the same procedures. Studies consistently show Medicare pays about 40% less than private insurers on average. For example, a knee replacement that Medicare reimburses at $17,000 might cost a private insurer $30,000-50,000 at the same hospital.
This is why provider "charges" (list prices) are so much higher than Medicare payments — providers set charges to maximize private insurance reimbursement, while Medicare applies its own fee schedule regardless. The result: providers charge $3.5T+ to Medicare but receive $940B.
See how different doctors compare on pricing, volume, and specialties.
See exactly where your Medicare premiums and tax dollars go.
Browse 7,500+ Medicare procedure codes with cost and utilization data.
What providers charge vs what Medicare pays — the 3.7x gap.
These are averages, not quotes. Actual Medicare payments vary by provider location (geographic cost adjustments), facility vs office setting, and whether the provider accepts assignment. Use these estimates as a starting point, not a guarantee.
Your out-of-pocket cost is different. Medicare typically pays 80% of the approved amount. You pay 20% coinsurance plus any applicable deductible. If you have Medigap or other supplemental insurance, your share may be lower or zero.
Part B only. This calculator covers Medicare Part B (physician/outpatient) services. Hospital inpatient costs (Part A) and pharmacy drugs (Part D) use different payment systems not included here.
Data vintage. Costs are based on 2024 CMS data — the most recent available. Medicare fee schedules are updated annually, so current-year payments may differ slightly.
• The most expensive single procedure code in Medicare is J0178 (Eylea injection) — costing Medicare over $3 billion annually for a single drug injected into the eye.
• A standard office visit (99213) costs Medicare about $75-95, but providers charge $200-400+ for the same visit.
• Medicare's fee schedule has over 7,500 procedure codes, from $3 urine tests to $50,000+ surgical procedures.
• The geographic adjustment means the same procedure costs Medicare 20-30% more in San Francisco than in rural Mississippi.
Note: All data is from publicly available Medicare records. OpenMedicare is an independent journalism project not affiliated with CMS.