Case studies
Four payer files, four provable gaps
Every figure below comes from a payer's or hospital's own disclosed data — CMS fee schedules, the NPPES NPI registry, and federally mandated price-transparency files. No modeled estimates, no assumptions about what a “fair” rate should be. Pick a case study to dig in.
Physician fee schedule · pain management
Same code, same locality, different paycheck
A pain management specialist in Brownsville, TX vs. two interventional pain peers in McAllen, TX — same GPCI locality (Rio Grande Valley), same CPT codes, same office setting.
$415.46
Brownsville specialist
CPT 64635, Facet RFA · same GPCI locality as McAllen
$623.57
McAllen peer average
Peer A ($622.67) & Peer B ($624.47) · same code, same office setting
+50%
Gap, identical locality
Not explained by geography — both are Rio Grande Valley
Why McAllen, not Sugar Land
Sugar Land sits in the Houston-area Medicare locality — a different, typically higher-cost GPCI zone than Brownsville. McAllen doesn't: both McAllen and Brownsville fall in the Rio Grande Valley / “Rest of Texas” locality, so this comparison isolates provider-level rate differences from geographic payment adjustment. Measured against each provider's own locality's official CMS rate, the Brownsville specialist sits at ~95–103% — essentially at par. McAllen peers run 105–155% of their own locality's rate.
Brownsville vs. McAllen — every shared code
| Code | Description | Brownsville specialist | McAllen peer A | McAllen peer B | Gap vs. McAllen avg. |
|---|---|---|---|---|---|
| 62321 | Interlaminar ESI | $246.77 | $246.87 | — | +0.0% |
| 64483 | Transforaminal ESI | $230.93 | $343.96 | — | +49.0% |
| 64493 | Lumbar Facet Injection | $167.21 | — | $248.84 | +48.8% |
| 64635 | Facet Joint RFA (1st nerve) | $415.46 | $622.67 | $624.47 | +50.1% |
| 64636 | Facet Joint RFA (add'l nerve) | $224.62 | $336.40 | $337.37 | +50.2% |
Medicare-allowed amount per service, office place of service. The two McAllen peers don't bill identical code sets, but on every code they share with the Brownsville specialist, the premium lands within one point of ~50%.
Ruling out geography and setting
Place of service
100% office
All three providers bill non-facility (POS: O)
GPCI locality
Same locality
Brownsville & McAllen — both Rio Grande Valley / Rest of Texas
Result
Gap stands
Neither variable explains the ~50% reimbursement gap
Commercial cross-check — BCBS TX “Blue Essentials”
| Code | Brownsville specialist | McAllen peer A | McAllen peer B | Harlingen peer C |
|---|---|---|---|---|
| 64483 | $233 – $280 | $280 | $233 – $280 | $280 |
| 64493 | $170 – $204 | $204 – $286 | $170 – $204 | $281 – $434 |
| 64635 | $415 – $498 | $391 – $498 | $415 – $498 | $391 – $604 |
Key finding — the Harlingen peer (same locality)
Top-tier rate reaches $434 on 64493 (+113%)vs. the Brownsville specialist's max $204, and $604 on 64635 (+21%)vs. their max $498 — a same-locality peer paid meaningfully more even on this commercial plan. The Brownsville specialist and McAllen peer B otherwise run near-identical negotiated rate sets on this plan, so peer C's tier is the outlier, not the norm — worth cross-checking against Aetna, Cigna, and UnitedHealthcare before finalizing a commercial ask.
Turning the gap into a negotiation plan
- 1
Benchmark against same-locality peers first
A same-GPCI comparison like McAllen vs. Brownsville is the hardest to dispute in a negotiation — it can't be waved away as a geography or cost-of-living difference.
- 2
Audit for coding and modifier gaps
A gap this size on an identical CPT code often traces to modifier usage, units billed, or missed add-on codes — verify billing captures every eligible add-on level (64484, 64494, 64636).
- 3
Anchor the commercial ask to the locality-matched peer rate
If a same-locality peer collects $623 for 64635 vs. your $415, use that as the opening commercial-rate ask — it's the most defensible number available.
- 4
Track add-on code capture rate
Compare first-level vs. additional-level code ratios between practices to spot missed add-on billing opportunities across the panel.
- 5
Refresh the benchmark every rate year
The Medicare Physician Fee Schedule and locality GPCI update annually — a peer-rate benchmark from last year can be stale by the time you renegotiate.
Sources & methodologyNPPES NPI Registry (provider identification) · CMS Medicare Physician & Other Practitioners by Provider and Service (data.cms.gov) · 100% CMS locality benchmark calculated as (Work RVU × Work GPCI + Non-Facility PE RVU × PE GPCI + Malpractice RVU × MP GPCI) × CY2025 conversion factor $32.3465, RVUs from AANEM's 2024–2025 RVU Comparison, GPCI from CMS's official 2025 localities file · Commercial rates from BCBS Texas “Blue Essentials” Machine-Readable File, in-network-rates dated 2026-06-14, professional office/POS-11 tier. Reflects Medicare FFS and one commercial payer's MRF only.
What PayerParity builds from this
- Evidence, not anecdote. Every argument comes from the payer's or hospital's own disclosed file, cross-referenced against CMS's own pricing tools.
- Four data models, one question. Physician fee schedules, inpatient DRGs, and specialty drug contracts all reduce to the same test: what does this exact code pay elsewhere, and why not here?
- Replicable, any market. The same CMS-baseline method extends from a single CPT code to a full DRG or drug-spend book, in any specialty or geography.
See what your own fee schedule is leaving on the table
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