What do payers pay ophthalmology groups in NC?

Across 413 NPIs, the median published rate is 83% of locality-adjusted Medicare (September 2026 files).

Data as of the September 2026 payer files.

Across 91 procedure codes and 3 payers, the median published rate is 111 percent of locality-adjusted Medicare in the September 2026 payer files. Cigna publishes the highest median at 127 percent and Aetna the lowest at 93 percent, a spread of 34 points on identical work. 2 of 3 payers sit at or above Medicare and 1 below it. The best-covered row rests on 413 confirmed NPIs, and any combination under five is withheld rather than shown thin. These are contracted amounts the payer published, not what a practice was paid, and every row clears the ghost-rate filter, so each NPI counted here actually billed the code in the Medicare utilization file.

Published rates

ASC versus hospital savings appears only when a hospital outpatient rate is published. Hospital OPPS is not in this phase.

Median rate by payer, percent of Medicare

Solid line 100% of Medicare.

How this is measured

Rates come from each payer's published Transparency in Coverage machine-readable file, filtered to this specialty's codes and to NPIs the CMS Medicare utilization file shows billing that code. Percentiles are computed per payer, code and site of service across those NPIs, then divided by the locality-adjusted Medicare amount for the same code and place. Full methodology.

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