Procedure Price Method v1.0

1. Principle: Medicare anchor separate, self-pay only when verified

Every procedure page has two distinct jobs. First, show the Medicare (CMS) rate as a separate anchor, labeled with its payment system, source, and year. Second, discuss self-pay pricing only to the extent a public source verifies it. The two are never blended into a single range, an average, or a multiple presented as a price.

At launch, all 10 procedure pages ship a verified Medicare anchor. Self-pay ranges are not published yet on any launch page, because no self-pay range for these CPT codes met the verification rule below at launch. Each page states that plainly and tells the reader how to obtain a real cash quote. That absence is a feature of the method, not missing content.

2. Sources used

• CMS Physician Fee Schedule CY2026, published by WPS GHA (Medicare Administrative Contractor) for Michigan Locality 01, effective January 1, 2026 (fee schedule file updated September 15, 2026)
• CMS Hospital Outpatient Prospective Payment System (OPPS) CY2026 Final Rule CMS-1834-FC, effective January 1, 2026 - official addenda published by CMS: Addendum A payment rates, Addendum B code assignments, Addendum M composite assignments (Addendum A and B versions dated December 11, 2025)
• CMS Physician Fee Schedule conversion factors CY2026 final: $33.4009 for non-qualifying APM participants and $33.5675 for qualifying APM participants (CMS-1832-F), replacing the single CY2025 factor of $32.3465 (CMS-1807-F)

Each anchor in the checked-in data file (src/data/procedures.json) records sourceName, sourceYear, and verifiedDate of 2026-10-18. The same citation is rendered on the procedure page and inside the Price Anchor Explorer. A figure without a completed citation is not rendered.

3. What counts as verified

A CPT figure is verified when an editor has located it in a named CMS publication or a Medicare Administrative Contractor publication of the CMS fee schedule, or in the CMS final rule or its published addenda as distributed by CMS or a named summarizer that reproduces the CMS table, and has recorded the exact amount, code, component (global, 26, TC, facility, nonfacility, or APC), source name, source year, and verification date.

At launch:

• Physician Fee Schedule global, professional (26), and technical (TC) amounts for CPT 70551, 70553, 70450, 74177, 76700, 77067, 71046, and 93306 were verified in the WPS GHA CY2025 fee schedule file for Michigan Locality 01, effective January 1, 2025.
• Physician Fee Schedule facility and nonfacility amounts for CPT 45378 (colonscopy) and 43235 (EGD) were verified in the same WPS GHA file.
• OPPS composite APC national unadjusted rates for APC 8004, 8005, 8006, 8007, and 8008 were verified in the CY2025 OPPS Final Rule summary reproducing CMS-1809-FC tables (Health Policy Solutions, distributed via AAPM, November 2024), effective January 1, 2025.

At the October 18, 2026 re-verification, every anchor was rolled forward to the current fee schedule year:

• Physician Fee Schedule amounts for all 30 procedures (global, professional 26, and technical TC components, or facility and nonfacility amounts, as each code is published) were verified in the WPS GHA CY2026 fee schedule file for Michigan Locality 01, effective January 1, 2026 (file updated September 15, 2026). Internal checks: each global amount equals its professional plus technical components to the cent (within one cent of published rounding), and the file's non-participating and limiting-charge columns reproduce at 95 percent and 115 percent of the participating amount.
• OPPS facility amounts for the 22 procedures that carry one were verified in the official CY2026 OPPS Final Rule addenda published by CMS for CMS-1834-FC: Addendum A payment rates for each APC, Addendum B code assignments and status indicators, and Addendum M composite assignments (Addendum A and B versions dated December 11, 2025). Every APC assignment and status indicator on the site was rechecked against Addendum B; none changed for the 30 codes.
• CY2026 is the first year with two Physician Fee Schedule conversion factors: $33.4009 for non-qualifying APM participants and $33.5675 for qualifying APM participants (CMS-1832-F). The amounts on this site are the participating amounts published in the WPS GHA file named above.
• Code-family tables on the procedure pages and the emergency visit level anchors (added October 22, 2026) use a second checked-in file, billing-anchors-2026.json. Its fee schedule amounts are computed from the CMS CY2026 national relative value file (RVU26D, October 2026 release) and the CY2026 geographic practice cost indices for Michigan Locality 01 with the $33.4009 conversion factor; that calculation reproduces the WPS GHA amounts above to the cent (for example $192.65 for CPT 70551 and $378.46 and $172.49 for CPT 45378). Its hospital amounts are single-service APC rates and minimum unadjusted copayments from the CMS OPPS October 2026 Addendum A and Addendum B (updated October 15, 2026). Verified 2026-10-22. From the same date, every OPPS figure shown for one code is the single-service APC payment for that code billed alone; the imaging composite APCs recorded at launch (8004 to 8008) are shown only as a separate, labeled multi-study figure, because they apply only when several qualifying studies are billed on one claim.

Locality note: PFS amounts are locality-adjusted. The Michigan Locality 01 amounts are valid Medicare anchors for order-of-magnitude and facility-comparison purposes. They will differ from the amount in another locality and from the national unadjusted amount. Pages state the locality source so the reader can judge applicability. OPPS amounts are national unadjusted rates before wage-index adjustment.

4. Inclusion rules for procedure pages

• The page must identify the CPT code and descriptor and note the common code variants that change the price (with versus without contrast, complete versus limited, screening versus diagnostic, biopsy added).
• The page must list what the price includes and what it usually excludes, by layer (professional, facility, anesthesia, pathology).
• The page must explain why prices vary for that code, including the facility-type lever specific to the code.
• The Medicare anchor, where verified, must be shown with component detail and full citation. Where no anchor was verified for a component, that component is omitted rather than estimated.
• Every page must carry the instruction: confirm your price in writing before service.
• No page may contain diagnosis, treatment, or should-you-get-this-test content.

5. When a self-pay range may be added

A self-pay range may be added to a procedure page only when all of the following hold:

1. The range comes from a named public source that states its population, geography, date range, and method (for example a state price transparency database with published methodology, or a peer-reviewed or government study with a reproducible extract).
2. The source distinguishes the CPT code and setting, or the limitation is stated on the page next to the range.
3. The Medicare anchor remains displayed separately and is not averaged into the range.
4. The page records the self-pay source with the same citation discipline as the Medicare anchor.

Blogger roundups, facility marketing pages without method, single-facility anecdotes, and chargemaster extracts do not meet this rule.

6. Limitations of hospital machine-readable files, stated plainly

Federal price transparency rules require hospitals to publish machine-readable files (MRFs) of standard charges. Those files are useful for researchers and negotiators. They have sharp limits as patient price information, and MyCarePrice does not present MRF list prices as what patients pay:

• Gross charges are list prices. The gross charge is the chargemaster amount before any payer contract, discount, or cash policy. Almost no patient pays the gross charge.
• Payer-specific negotiated charges vary by plan. The same CPT code at the same hospital can carry dozens of negotiated amounts. A single extracted number hides the variation that determines an insured patient's allowed amount.
• Cash prices in MRFs are inconsistently defined. Some files list a discounted cash price; many do not, or define it differently. Cross-hospital cash comparisons from raw MRFs are unreliable without manual verification of each file's definitions.
• Files are stale and error-prone. Update cadence, code mapping, and unit definitions differ. An extracted price may describe a different code variant or bundle than the one ordered.
• The professional fee is usually absent. MRFs describe facility charges. The radiologist, cardiologist, endoscopist, anesthesia, and pathology bills that complete the patient's total are generally not in the hospital file.
• What changed in the files on January 1, 2026. Under the CY2026 OPPS Final Rule (CMS-1834-FC), when a payer-specific negotiated charge is based on a percentage or an algorithm, hospitals must now encode the median allowed amount, the 10th percentile allowed amount, the 90th percentile allowed amount, and the count of allowed amounts behind those figures, calculated from electronic remittance (EDI 835) data over a lookback period of at least 12 and no more than 15 months before the file is posted. These elements replace the estimated allowed amount. CMS delayed enforcement of the new elements until April 1, 2026. The new fields describe what plans actually allowed on past claims; they are still not a quote for your care, and the limits above still apply. Source: CMS fact sheet, CY 2026 OPPS and Ambulatory Surgical Center Final Rule - Hospital Price Transparency Policy Changes, checked October 18, 2026.

For those reasons Method v1.0 uses MRFs, if at all, only as a lead for manual verification - never as a published patient price without the full verification in section 5.

7. What we will not do

• Invent, interpolate, or extrapolate a price, range, average, or multiple.
• Blend a Medicare anchor into a self-pay range or present a multiple of Medicare as a cash price.
• Present a gross charge or any MRF list price as what patients pay.
• Publish a figure without a named source, year, and verification date.
• Publish diagnosis, treatment, or appropriateness content alongside prices.

8. Updates and corrections

Anchors are re-verified when CMS publishes a new fee schedule year or when a correction is confirmed. The verification date on each page and in the data file changes when its anchor is re-verified. Send corrections through the contact form with the page URL. Confirmed corrections are fixed in the data file first, then re-rendered to the page and explorer so all surfaces stay in sync.

Method changes increment the version number (v1.1, v2.0) with a dated change note appended below. The method that produced a given figure is the version in effect on its verification date.

Change log

• v1.0 - 2026-10-04: Launch method. 10 procedures with verified PFS anchors; OPPS composite anchors for MRI, CT, and ultrasound families; no self-pay ranges published; facility-type and playbook content under the inclusion rules above.
• v1.2 - 2026-10-18: Scheduled re-verification. All 30 PFS anchors and all 22 OPPS anchors rolled from CY2025 to CY2026 (WPS GHA CY2026 fee schedule file, Michigan Locality 01; CMS OPPS CY2026 Final Rule CMS-1834-FC addenda). CY2025 OPPS amounts are retained in the data file as the prior-year field. The CY2026 hospital price transparency allowed-amount elements were added to section 6. No self-pay ranges added, and no procedure pages added or removed.
• v1.1 - 2026-10-04: Expansion to 30 procedures. 20 procedures added with the same verification rule: PFS anchors read from the WPS GHA CY2025 fee schedule file for Michigan Locality 01 (the method reproduced the launch anchor for CPT 70551 to the cent before any new figure was added), and OPPS facility anchors read from the official CY2025 OPPS Final Rule addenda (Addendum A payment rates, Addendum B code assignments, Addendum M composite assignments). Codes with no OPPS payment (status indicator A or B) ship the PFS anchor only, with the reason stated on the page. No self-pay ranges added.