Medicare Part B Billing Explained: Submitted Charges, Allowed Amounts and Payments

Where the numbers come from

CMS publishes the Medicare Physician & Other Practitioners - by Provider and Service dataset. Each row describes one clinician, identified by NPI, and one service, identified by a HCPCS code, which is the code set used to bill Medicare for procedures, visits and other services. Each row shows how many services were billed, to how many patients, and the average amounts.

What the data covers

According to the CMS methodology for this dataset:

• It is based on Part B fee-for-service claims, that is, Original Medicare. It does not include information for patients enrolled in any form of Medicare Advantage plan.
• Any aggregated record derived from 10 or fewer beneficiaries is excluded, to protect patient privacy. A clinician who performed a service for only a few Medicare patients will have no row for it.
• Each release covers one calendar year of claims, and CMS publishes it well after the year ends.

So the data does not show a clinician's full practice. Services for patients with Medicare Advantage, private insurance or Medicaid are not in it.

The four amounts in the data

The CMS data dictionary defines each average amount:

Average submitted charge

The average of the charges that the provider submitted for the service. This is the practice's own listed charge. It is set by the practice, and Medicare does not pay it as billed.

Average Medicare allowed amount

The average of the Medicare allowed amount for the service. CMS defines it as the sum of the amount Medicare pays, the deductible and coinsurance amounts that the beneficiary is responsible for paying, and any amounts that a third party is responsible for paying. It is the total recognized for the service under Medicare rules, often called the Medicare-approved amount.

Average Medicare payment amount

The average amount that Medicare paid after deductible and coinsurance amounts have been deducted. It is always lower than the allowed amount when the patient owed a deductible or coinsurance.

Average Medicare standardized amount

The Medicare payment after standardization, which removes geographic differences in payment rates. CMS provides it so that payments can be compared across regions.

Why the submitted charge is higher

The submitted charge is set by the practice. Medicare does not pay it as billed: it pays based on the Physician Fee Schedule, which assigns an amount to each service. That is why the average submitted charge in the data is usually well above the average allowed amount.

What happens to the difference depends on assignment. Medicare.gov explains on its assignment page that a provider who accepts assignment agrees to charge you only the Medicare deductible and coinsurance. A non-participating provider who does not accept assignment can, in many cases, charge up to 15% above the Medicare-approved amount. So with assignment you never pay the gap between the submitted charge and the allowed amount, and without assignment the extra you can be charged is, in many cases, capped by the limiting charge.

How the fee schedule sets the allowed amount

You can look up the fee schedule amount for a HCPCS code with the CMS Physician Fee Schedule Look-Up Tool. The amount for the same code is not the same everywhere:

• Location: the tool's overview explains that each Medicare payment locality has a geographic practice cost index (GPCI) that adjusts the payment for local costs.
• Setting: the tool's documentation uses different practice expense values for services in a facility, such as a hospital, and in a non-facility setting, such as an office.
• Participation: the same documentation explains that the amount for a non-participating physician is 95% of the amount for a participating one.

These differences are why the average allowed amount for the same code can differ between two clinicians, even in the same city.

How your coinsurance is calculated

For most Part B services, Medicare.gov's costs page says you pay 20% of the Medicare-approved amount after you meet the yearly Part B deductible, which is $283 in 2026. The deductible is paid once a year, and Medicare.gov's preventive services page notes that you pay nothing for most preventive services from a provider who accepts assignment.

A worked example with illustrative numbers

The numbers below are made up to show the arithmetic. They are not real Medicare rates.

• Submitted charge: $200.
• Medicare-approved amount: $100.
• You have already met your Part B deductible for the year.
• Your coinsurance: 20% of $100 = $20.
• Medicare's payment: the remaining $80, before any other adjustments.

If the provider accepts assignment, you owe the $20 coinsurance, not a share of the $200.

What this data can and cannot tell you

Useful for

• Seeing which services a clinician billed most often to Original Medicare.
• Understanding the typical Medicare allowed amount for a service before a visit.
• Comparing how a clinician's submitted charges relate to what Medicare allows.

Not suitable for

• Estimating a private insurance or Medicare Advantage bill. Those plans pay their own rates, which this data does not include.
• Judging quality. A high or low volume says nothing about outcomes.
• Predicting your exact cost. Your bill depends on the exact codes billed, the setting, your coverage and whether you have met your deductible.
• Finding every service a clinician offers. Services with few Medicare patients are excluded.

For a real estimate, ask the office which codes they expect to bill and what they will charge, and check with Medicare or your plan.

How T-MedInfo shows Part B data

Clinician profiles on this site include a Medicare Part B section when CMS data lists services for that NPI. For each data year we show the HCPCS code and description, the number of services, the number of Medicare patients, the average submitted charge and the average Medicare allowed amount, taken directly from the CMS dataset. The data year is shown with the table, and you can switch between the years we have loaded.

Next to the table we state that the data covers Original Medicare Part B claims only and that CMS does not publish services provided to 10 or fewer beneficiaries. We do not estimate prices, fill in missing years or add numbers that are not in the CMS data.

For the difference between assignment, participation and opting out, see our Medicare assignment guide.