The gap keeps widening
The red line is what providers billed Medicare; the teal line is what Medicare allowed. Both climb, but the charges climb faster - the markup went from 2.78x in 2013 to 3.24x in 2024. The shaded wedge between them is the gap.
Where the markup lives
Every specialty bills over what Medicare allows, but the multiple ranges widely. Emergency medicine submits 6.23x; primary care and podiatry sit near 2x. The steepest of all are the anesthesia trades off this chart - Certified Registered Nurse Anesthetist (CRNA) alone bills 10.08x. Bars show the 18 largest specialties by Medicare dollars; the dashed line is the national 3.25x.
Submitted charge as a multiple of the Medicare-allowed amount · right column = allowed $
The markup has a geography
The same office visit is billed at very different multiples depending on where the provider practices. Alaska, Wisconsin and New Hampshire run the steepest markups; Idaho and Montana the gentlest. The map shades the submitted-to-allowed ratio; the table keeps the exact figures.
- 2.43-2.96x
- 2.96-3.15x
- 3.15-3.34x
- 3.34-4.78x
State table - the ranked source of truth
Submitted charges divided by the Medicare-allowed amount, all providers in the state, quartile classes · Darker = a steeper markup · Real CMS 2024 by-Provider file · 50 states + DC; territories reported but not on this 50-state map
The same markup, two more ways
A service billed inside a hospital or surgery center carries a far steeper markup than the same work in a doctor's office - the facility bills separately, and the charge inflates with it.
Grouped by the provider's Rural-Urban Commuting Area. Metropolitan practices bill the steepest multiples; the markup eases step by step out to the most rural providers.
What the money actually buys
Behind the markup, ordinary care dominates the spend. The single biggest line is a routine established-patient office visit - Medicare allowed $12.2B for code 99214 alone. Bars show Medicare-allowed dollars; each service's own markup sits at right.
- 1 99214 Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more $12.2B 104M svcs 2.34x
- 2 99213 Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more $5.8B 69M svcs 2.25x
- 3 99233 Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes $2.7B 23M svcs 2.82x
- 4 99232 Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes $2.6B 35M svcs 2.67x
- 5 J0178 Injection, aflibercept, 1 mgdrug $2.2B 3M svcs 2.09x
- 6 99215 Established patient office or other outpatient visit with high level of medical decision making, if using time, 40 minutes or more $2.1B 13M svcs 2.50x
- 7 J9271 Injection, pembrolizumab, 1 mgdrug $2.1B 38M svcs 2.46x
- 8 66984 Removal of cataract with insertion of prosthetic lens $2.0B 8M svcs 4.18x
- 9 99204 New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more $2.0B 13M svcs 2.60x
- 10 A0427 Ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency) $1.9B 4M svcs 3.13x
- 11 J2777 Injection, faricimab-svoa, 0.1 mgdrug $1.9B 54M svcs 1.93x
- 12 99223 Initial hospital care with moderate level of medical decision making, if using time, at least 75 minutes $1.7B 10M svcs 3.39x
Total Medicare-allowed dollars per HCPCS service code, national, 2024 · Markup = submitted / allowed for that service · Drug and biological codes (tagged) carry inflated markups because they are billed per tiny unit against a set payment rate - read those ratios with care.