What is rate benchmarking in healthcare?

Comparing what a payer actually pays for a billing code — the negotiated rate — against the full distribution of what every other provider in that market is paid for the same code. It answers 'is my rate competitive' with a percentile, not a guess.

What is the difference between a negotiated rate and a chargemaster price?

A chargemaster (or list) price is the sticker price a hospital sets before any discount — almost nobody pays it. A negotiated rate is what a specific payer contractually agreed to pay for that code. Rate benchmarking uses negotiated rates, because that is the number that actually shows up in revenue.

Do commercial payers always pay more than Medicare?

No. For primary care office visits in particular, commercial negotiated rates frequently sit at or below the Medicare amount — the market data above shows several payer medians for CPT 99214 in Texas below the $137.41 Medicare rate. Procedural and surgical codes usually skew the other way.

How many rates do I need to see before a number means anything?

Enough to trust a percentile, not just an average — the distributions above are built from thousands of published rate rows per code and payer. A benchmark from a handful of data points is closer to a guess than a market read.

Where does the rate data come from?

Payer machine-readable files published under the CMS Transparency in Coverage rule, plus the CMS Medicare Physician Fee Schedule. It is disclosed data — we organize and index it, we do not survey or estimate it.

Rate Benchmarking

What does insurance actually pay? Now you can see it.

Not the chargemaster sticker price — the negotiated rate every payer actually reimburses. MedReveal shows you the full market distribution for any CPT or HCPCS code, by payer, by state, so you can benchmark a rate instead of guessing at it.

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Why a benchmark, not an average

A rate means nothing until you know where it sits

Negotiated rates, not chargemaster prices

A hospital price list is what nobody actually pays. We index what each payer negotiated and actually reimburses — the number that determines your revenue.

Every payer, side by side

UHC, Aetna, Cigna, BCBS and more, for the same code, in the same market — so "what does insurance pay for this" has a real, comparable answer.

The full distribution, not one average

A single average hides the spread. See the 25th, median, 75th and 95th percentile so you know if a rate is typical or an outlier before you act on it.

Medicare as the common reference

Every rate is shown against the current Medicare amount for that code and locality — the one benchmark every payer, provider and consultant already speaks in.

What the output looks like

The office visit, benchmarked

CPT 99213, 99214 and 99215 — the established-patient office visit codes behind most "how much does a doctor visit cost" searches. Family Medicine, professional claims, Texas. Every figure below is a live MedReveal query result.

Market benchmarking report: Family Medicine professional claims in Texas, office visit codes, against Medicare
Code	Min	Q1	Median	Mean	Q3	P95	Medicare	Median % of Medicare
99213Office visit, established patient, low complexity (20 min)	$31.40	$51.13	$62.15	$70.15	$79.96	$129.69	$96.33	65%
99214Office visit, established patient, moderate complexity (30 min)	$48.29	$77.49	$92.50	$104.50	$116.69	$190.54	$137.41	67%
99215Office visit, established patient, high complexity (40 min)	$68.21	$107.72	$127.60	$144.30	$159.20	$262.52	$195.13	65%

Source: UHC published negotiated rates, professional billing class, filtered to Family Medicine taxonomies, TX. Medicare reference: Medicare, Houston locality, non-facility, CMS Physician Fee Schedule 2025.

The counterintuitive part

Medicare pays $137.41 for CPT 99214 in Houston. The UHC median for the same code, same specialty, same state is $92.50 — 67% of Medicare. Primary care office visits are one of the few code families where commercial insurers routinely pay below the Medicare rate, which is exactly the kind of fact a benchmark surfaces and an average hides.

Benchmark your own rate against the market

Same code, CPT 99214 — Office visit, established patient, moderate complexity. An illustrative provider rate of $95.00 lands at the 53rd percentile on UHC but only the 7th on BCBS — the same rate reads very differently payer to payer.

Q1–Q3MedianMeanMedicare $137Client22ndPercentile

Family Medicine, professional rates, TX · whiskers are Tukey bounds (1.5×IQR) · full figures in the table below

Full rate distribution by payer for CPT 99214, including the client's contracted rate and percentile
Payer	Client rate	Percentile	Min	Q1	Median	Mean	Q3	P95	Count	vs Median
UHC	$95.00	53rd	$48.29	$77.49	$92.50	$104.50	$116.69	$190.54	3,930	+$2.50
Aetna	$95.00	20th	$25.00	$111.93	$116.82	$132.64	$126.44	$243.47	3,656	$-21.82
Cigna	$95.00	36th	$57.90	$87.19	$105.15	$115.72	$123.56	$202.61	4,054	$-10.15
BCBS	$95.00	7th	$88.56	$111.56	$119.24	$123.56	$130.76	$140.24	3,874	$-24.24

How it works

From a code list to a percentile

Pick the codes

Search by CPT, HCPCS, specialty or service group — the codes that actually drive your volume, not a generic sample.

Pull the market distribution

For each code and payer, get the full spread of negotiated rates: min, 25th, median, 75th, 95th percentile, and the Medicare amount.

Place your own rate

Drop your contracted rate onto the distribution. The result is a percentile, not an opinion — you are at the 20th or the 80th, for each payer.

Act on the gap

A rate sitting below the 25th percentile is a renewal target. One above the 75th is a rate worth defending. Either way, you know before you walk in.

Who benchmarks rates, and why

Contract renewal prep

Walk into a payer renewal with the market distribution for your top codes, not a percentage increase you cannot defend.

Fee schedule design

Setting a new fee schedule or master rate? Benchmark it against real market data before you commit to it, code by code.

Market entry and site selection

Sizing the reimbursement landscape in a new market before committing capital to a new location or service line.

Competitive intelligence

See where your rates sit against every payer in your specialty and state — not just the one contract in front of you.

Questions about rate benchmarking

What is rate benchmarking in healthcare?: Comparing what a payer actually pays for a billing code — the negotiated rate — against the full distribution of what every other provider in that market is paid for the same code. It answers 'is my rate competitive' with a percentile, not a guess.
What is the difference between a negotiated rate and a chargemaster price?: A chargemaster (or list) price is the sticker price a hospital sets before any discount — almost nobody pays it. A negotiated rate is what a specific payer contractually agreed to pay for that code. Rate benchmarking uses negotiated rates, because that is the number that actually shows up in revenue.
Do commercial payers always pay more than Medicare?: No. For primary care office visits in particular, commercial negotiated rates frequently sit at or below the Medicare amount — the market data above shows several payer medians for CPT 99214 in Texas below the $137.41 Medicare rate. Procedural and surgical codes usually skew the other way.
How many rates do I need to see before a number means anything?: Enough to trust a percentile, not just an average — the distributions above are built from thousands of published rate rows per code and payer. A benchmark from a handful of data points is closer to a guess than a market read.
Where does the rate data come from?: Payer machine-readable files published under the CMS Transparency in Coverage rule, plus the CMS Medicare Physician Fee Schedule. It is disclosed data — we organize and index it, we do not survey or estimate it.

Find out where your rates actually stand

Look up any CPT or HCPCS code for free, or send us your code mix and payer set for a full benchmarking pass.