Average Copay For Doctor Visit


Suppose a patient has a health insurance plan with a $30 copay to visit a primary care physician, a $50 copay to see a specialist, and a $10 copay for generic drugs. You pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you're a hospital inpatient), outpatient therapy, and Durable Medical Equipment (DME) Glossary. How a deductible works. With a deductible plan, you pay the full cost for many services until you reach a set amount for the year — your deductible. After you reach your deductible, you’ll usually start paying just a copay or coinsurance: A copay is a set amount you pay for a service. A coinsurance is a percentage of the full cost of a service.

Primary Listings

Hospital Clinic and Office Visit Charges and Medicare Payments 2018

Find Hospital Clinic and Office Visit charges (average price) for 2018, and the payments that Medicare made. Find average charges for about 13,000 different codes (depending whether office or hospital facility-based). National average prices are in the Procedure Summary file. Extremely difficult to use, even if somewhat familiar with using Excel files. File uses HCPCS codes. The most common codes were office visits 99213 (average charge about $138) and 99214 (average charge about $208). Medicare allowed about $71 for code 99213 and about $105 for 99214. Therapeutic exercise (code 97110) had average charge of $61, with Medicare allowing about $26. Lab tests, x-ray, emergency department visits are in the file. An Emergency Department visit (code 99285) had a national average facility charge of $1,118, with Medicare allowing just $174. Physician charges may be available in the Provider Summary Table. Calendar year 2018 data from CMS updated November 2020.

Office Visit Costs Allowed by Medicare (2012)

Medicare reported its average allowed cost for established patients’ physician office visit in 2012: $69 for CPT code 99213 (the most common office visit), $102 for 99214. For new patients, office visit 99203 was $103, and 99204 was $158 Allowed by Medicare. More allowed costs and Medicare payments are shown, including ear wax removal ($49 allowed) and Annual wellness visit for new Medicare enrollees ($165 allowed, and $165 paid by Medicare). Average payments exclude the amount the patient pays directly for co-pays and deductibles. Consumers are expected to know CPT codes and how to use Excel files. Terribly outdated; 2012 data published Sept. 2013. No updates as of April 2021.

Childbirth – Average Total Cost for Having a Baby (AHRQ MEPS pdf)

Childbirth expenses. The average total cost of having a baby was about $12,000 in 2009 if you were privately insured and had an uncomplicated pregnancy. Adjusting for medical inflation (only), the total childbirth cost would be about $16,449 in 2020 dollars. The estimate includes actual payments (expenditures, not charges) for all prenatal office visits, hospital childbirth (inpatient maternity and newborn delivery), prescription medications and other services for an uncomplicated pregnancy. In 2009, privately insured patients paid just under 10% out of pocket. Report from the Agency for Healthcare Research and Quality uses Medical Expenditure Panel Survey (MEPS) data for 2006 to 2009 patients; Research Findings #32 published June 2012. No update available as of September 2020.

Colorado 2019 Hospital Charges and Insurance Allowed AmountsEditor's Pick

Compare average charges at Colorado hospitals and amounts allowed by insurance in 2019. More than 50 types of hospitalizations. Click on View Reimbursement by Diagnosis or Insurance Provider to see average total charge in 2019, and how much the insurance company allowed. Amazingly, the patient’s responsibility (called member liability) is also shown. Consumers can appreciate the transparency between prices and insurance-allowed amounts. Example: Major joint replacement without complications (such as a hip or knee replacement) had an average price near $82,000 in 2019, and had an average insurance allowed cost near $34,000, or about 41% of the charges; member liability portion was an average of $1,607. Uncomplicated delivery had an average price of $16,151 in 2018, with insurance companies allowing $8,104, or about 50% of the charge. The patient responsibility averaged $1,714. (Maternity 2019 prices were not yet available.) Consumers are also able to see actual hospital prices (Click View Hospital Charges, then select year 2019 and procedure). Example: Average 2019 price for major joint (hip or knee) replacement without major complications at CO hospitals that performed at least 100 procedures, ranged from $40,685 in Delta, to $211,612 at North Suburban Medical Center in Thornton (over 5 times higher). Physician charges are not included in the inpatient costs. However, outpatient prices on average for the state, or region, are also available for 2019. Cataract surgery, colonoscopy, emergency room visit, knee arthroscopy, physician office visit and pregnancy test prices are examples of average charges available on the insurance report. Regions are Denver, Ft. Collins, Boulder, Colorado Springs, Grand Junction, Greeley, Pueblo, East and West. The information is jointly published by the Colorado Hospital Association, in conjunction with the state Division of Insurance’s Department of Regulatory Agencies (colo.gov). Updated 2020. The site’s timeliness, specific hospital prices listed, showing both charges and amounts allowed by insurance, along with the member patient responsibility, earns Editor’s Pick.

Assistance with doctor copays
Cosmetic (Plastic) Surgery Prices – Physician Fees, 2019 (pdf)Editor's Pick

Cosmetic surgery prices (plastic surgery) prices show physician fees for 2019. Find the average surgeon’s fees in this annual book of national statistics by The Aesthetic Society (also called the American Society for Aesthetic Plastic Surgery, or ASAPS). Average prices (2019) shown near the end of this document: e.g. $6,173 for tummy tuck, $3,792 to $4,085 for breast augmentation, $4,970 for breast lift, liposuction $3,382, eyelid surgery at $3,286, breast reduction $5,782 (male at $4,107), nose surgery $5,344, facelift at $7,821, botox injection at $379, laser hair removal $279, hyaluronic acid procedures $625, and nonsurgical fat reduction (such as CoolSculpting) $1,522. Cost numbers do not include facility fee nor anesthesia cost. Average number of procedures performed by ASAPS physicians shown for each type. See Quick Facts for how long cosmetic surgery or botox procedures or spider vein treatments take, average surgeon’s fees, how long before you’re back to work, etc. ASAPS active members are Board-certified in Plastic Surgery

Cost of an Office Visit (MEPS)

MEPS provides the average and median cost for a doctor’s office visit. Average cost paid (payments) for an office-based physician visit in 2016 was $265 (about $296 in 2020 dollars with medical inflation). For primary care (family medicine, internists and general practice) the 2016 average visit cost was $186. (For all 2016 numbers add about 12% to estimate 2020 prices.) Pediatrics came in at $169; psychiatry at $159, Dermatology at $268, OB/GYN was $280 per visit. Specialists in Ophthalmology were $307, but Orthopedics and Cardiology jumped to $419 and 335 respectively. Other specialists (as a group) averaged $365. Median or typical expenses were considerably lower at $116 overall, and $107 for primary care, $103 for psychiatry and ranging up to $134 median for ophthalmology and orthopedics. Mean out of pocket expense was highest for ophthalmology ($125) and lowest for pediatrics ($40). Primary care was $50 average out of pocket, if the patient had some responsibility. Statistical Brief # 517, pub. October 2018 by AHRQ using Medical Expenditure Panel Survey (MEPS) data.

Healthcare Expenses for Seniors (MEPS)

Healthcare expenses for seniors are outlined in this MEPS report on Health Care Expenditures for the Elderly Age 65 and over. Median annual expenditures were $4,206 per person (about $5,447 in 2020 dollars). Average annual expenses for those with expense were $9,863 in 2011. Using medical inflation rates, $9,863 is about $12,772 in 2020 dollars. Medicare paid over 62% (up considerably from 10 years earlier); private insurance paid 16%; out-of-pocket amount declined to 12%. 96% of seniors had some healthcare expense, most often office-based care and prescribed medicines. Medications took up 22% of the total, averaging $76 per purchase. For seniors, the inpatient room rate averaged $3,199 per day (sticker shock, and over $4,100 in 2020 dollars); ER visit was $884 on average; office visit was $228. MEPS Statistical Brief #429 uses 2011 data, published Jan. 2014. Add about 30% to account for medical inflation to 2020.

How Much Does an Office Visit cost compared to an ER visit?

An average physician office visit in 2017 cost $267, compared to $1,016 for an Emergency Room visit. Median expenditure per PERSON with an expense was $445 for office visits and $$776 for ER visits. The median expenditures cover total for the year, including multiple visits. Consumers should expect higher costs for 2020; $267 in 2017 is about $288 in 2020 using medical inflation factors. With inflation, $1,016 is about $1,096 in 2020 dollars. The data from MEPS (Medical Expenditure Panel Survey) informs consumers about the large difference between cost of care in a doctor’s office vs. Emergency Dept, nearly 4-fold. The most recent AHRQ Statistical Brief #318 that analyzes Expenses and Characteristics of Physician Visits in Different Ambulatory Care Settings is quite old – 2008 data, published in March 2011. It is mentioned here only for reference. Rimworld can't make medicine. The link is to the interactive database.

Maine Costs for Surgery, x-ray, imaging, lab tests (MHDO)

Compare costs in Maine for surgery, x-ray, imaging and lab tests across hospitals and medical groups. MHDO Maine Health Data Organization’s website shows average amount paid (median “cost”) by commercial insurance for surgery such as hip or knee replacement, shoulder arthroscopy, carpal tunnel, gallbladder removal; skin growth removal; lab tests such as strep, blood tests, urine. Imaging tests such as mammogram, x-ray, CT, MRI, ultrasound. Diagnostic procedures such as colonoscopy. Good news is that both physician and hospital charges for surgery are shown to give you an idea of total cost (and discounts); CPT codes listed. Costs for surgery, office visits and tests are from 2019-2020 claims, excluding Medicare and Medicaid. Search by city or zip code radius. From maine.gov

Average Copay For Doctor Visit For A

MN – Average Cost Per Procedure

Average cost per procedure at medical clinics in MN. The average cost per procedure (ACP) in Minnesota is defined as the Allowable charge that commercial health insurance plans (including the patient responsibility portion) PAID in 2018 to medical groups. Physician fees only, not facility fees. Median costs listed include Eye exams, Colonoscopy, Endoscopy with biopsy, Imaging (x-ray, CT, MRI, with and without contrast, screening mammogram, ultrasound), Lab tests (about 30 common tests), Vaccines, Mental health services and psychotherapy, Obstetric services (median $3,892 for physician services), Office Visits, Physical therapy, minor in-office surgery (e.g. skin lesion removal or vasectomy) and more. Medicare and Medicaid payment rates are also shown for reference. Minimum and maximum (range of costs) are reported for each procedure, visit or test. List of 2018 costs starts on page 22 of the 2019 Health Care Cost & Utilization Report Appendices. A few procedures show costs by medical group name (page 18). Report by Minnesota Community Measurement, mncm.org.

South Carolina – Average Medicaid Payments for Health Care Services – 2012

Find the average cost (payment) for healthcare services to Medicaid patients in South Carolina. SC Department of Health & Human Services shows how much the state paid for Medicaid costs, by type of service. It appears that the average amount paid per visit was about $38 (physician) and $88 (clinic); about $150 for a dental visit; $5,256 for a hospital inpatient stay, and $31,658 for a nursing facility resident in 2012. Consumers can also compare what each provider was paid by downloading the full datasheet (Excel file). Full charges (prices) are NOT shown. Medicaid Transparency Reporting project, FY 2012 data is latest available

Virginia Healthcare Prices – Ambulatory Surgery, Tests, Hospital Stays

Find Virginia Healthcare Prices for ambulatory surgery, tests and hospital stays. This site shows average price ALLOWED (commercial insurance prices) in 2018 for almost 40 common healthcare services in VA. Includes a mix of outpatient, clinic, hospital stays and other services such as an ambulance (median $550) or an emergency helicopter ride ($19,466). Examples: hospitalizations (maternity), outpatient xray/imaging, CT and MRI tests; colonoscopy, mammogram; inpatient or ambulatory surgery (e.g. hernia, gall bladder, knee replacement, tonsillectomy, kidney stones); and ER or well-child visits (median $126). Shows median and range of costs and provides a breakout by type of cost: facility, surgeon, anesthesiologist, etc. Also shows average price by setting: clinic vs. hospital vs. ambulatory surgical center; and region of Virginia. The median amount allowed for an ER visit (medium, code 99283) was $1,091. The 2020 report shows allowed amounts for each service that you or your insurance plan ACTUALLY PAID in 2018. More relevant than most pricing information, but lags in timeliness. Add at least 7% medical inflation rate to estimate 2020 costs. Virginia Healthcare Pricing Transparency, from Virginia Health Information (VHI), updated June 2020.

Office Visit Copay

VT Hospital Physician Office Visit Prices 2019

Compare what hospitals in Vermont are charging for physician office visits in 2018-2019. For example, code 99213 averages $155 for the physician. Since hospitals may charge an additional fee, the total charge in the state is about $208 per visit. Fees ranged from $98 at Northeastern VT Regional Hospital to $662 at North Country) for an established patient code 99213. Code 99214 average price is $262. New patient prices also shown. If non-hospital medical groups exist in VT, their fees are not shown. Provided by state of Vermont; prices good thru September 2019. No update available as of August 10, 2020.

Physician Payments: Average Medicare payment for 25 Common Office visits

Find out what Medicare paid for certain types of office visits and procedures in 2012. Average doctor’s price is NOT SHOWN, but only the allowed amount determined by Medicare, and how much Medicare paid on average (for every state). Must know how to use Excel files and billing code knowledge would also be helpful. Medicare paid $49 for a 99213 office code (15 minute office visit for an established patient) and $73 for a 25-minute office visit, and just $101 for a 60-minute visit (est. patients). If the patient was new, Medicare paid $73 on average for a 30 minute visit, and $116 for 45 minutes. Medicare’s annual wellness visit was paid at $165 for new enrollees, then $111 for subsequent annual visits. The most common EKG was paid at $14, ear wax removal at $36, pneumonia or annual flu shot at $23. Difficult file to use. Terribly dated; last updated Sept. 2013

Physician: Average Cost for 25 Common Ambulatory Surgery Center Procedures

Find the Allowed Medicare amounts (rather than prices) in the Ambulatory Surgery file for 25 Common high volume outpatient surgical procedures in an Ambulatory Surgery Center (not hospital-based). File shows what Medicare paid during 2012 for cataract surgery, different types of endoscopy, spinal injections, some hernia repairs, carpal tunnel release, kidney stone crushing, prostate biopsy (avg $530 paid on $670 allowable charge; full charge is not shown), correction of bunion, and more. Uses CPT codes, and all states are listed. Difficult file for consumers to use unless familiar with Excel. Terribly dated; last updated Sept. 2013. Federal government could show its commitment to price transparency by updating this file, and showing full sticker prices.

Other Helpful Listings

Average Cost of a Hospital ER Visit, MEPS

What Copay For Doctor Visits

What is the average cost of a hospital ER visit? According to the Medical Expenditure Panel Survey (MEPS), the average cost of an ER visit was $1,016 in 2017, up just 1.2% from 2016. (If you add medical inflation to 2020, the ER cost estimate would be about $1,096.) Many people made more than one trip to the Emergency Room in 2017. Consequently, the total expenditure per person with one or more ER visits during the year, was $1,482 in 2017, about the same as it was in 2016. The median expenditure per person with an expense was $776. The ER visit cost varied by age group. Adults ages 18 to 64 had the highest average visit cost at $1,203, followed by age 65+ at $830. Infants and children under age 18 cost $707 per visit on average. The average ER visit cost for someone uninsured was $887 in 2017. The federal government has not released costs for the 2018 or 2019 Emergency Department visits yet. It has discontinued detailed explanations, in favor of the online interactive tool – which we think is unfortunate. The interactive tool provides basic overall statistics only, and is difficult for many people to use. Note, the costs reported by MEPS are the expenditures (total amounts paid by all parties including insurance) for the ER visits. Actual charges would be substantially higher.

Harris Poll: Doctor Visit Satisfaction (2015)

On their most recent visit to a health care provider, 88% said they were satisfied with the experience. This compares to 91% satisfied with their last visit to a restaurant, for example, 63% satisfied with their last interaction with their health insurance company, and 59% satisfied visiting a mobile phone store. The doctor’s overall knowledge, training and expertise ranked the highest of the Very Important factors contributing to a positive experience. Overall, 62% of consumers ranked an online cost estimator as the number one technology they would like, with only 7% of doctors already having this in place. Harris Poll during September 2015, was published January 2016.