Prp i/hern init reduc >5 yr
About the analyst
Kevin Nyk analyzes hospital pricing data at BillRazor Research. He specializes in Medicare reimbursement patterns and chargemaster pricing across U.S. hospitals. Expertise: hospital pricing, Medicare rates, chargemaster analysis.
Understanding Prp i/hern init reduc >5 yr costs
Prp i/hern init reduc >5 yr (CPT code 49505) is a medical procedure . Medicare reimburses this procedure at $511 in a facility setting and $99 in a non-facility (office) setting. Hospital chargemaster prices for this procedure are typically 2x to 5x above Medicare rates.
Ambulatory Surgery Centers (ASCs) offer a lower-cost alternative at $1,685 — a potential savings of $-1,175 compared to the hospital outpatient rate. The actual amount you owe depends on your insurance plan, deductible status, and whether the provider is in-network. Uninsured patients should ask about the hospital's financial assistance policy — nonprofit hospitals are required to offer charity care under Section 501(r) of the Internal Revenue Code.
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Common billing errors for Prp i/hern init reduc >5 yr
Billing errors for Prp i/hern init reduc >5 yr include: upcoding to a higher-complexity code, unbundling components that should be included in a single charge, duplicate charges for the same service, charging facility fees when the procedure was performed in an office setting, and billing for services not actually rendered. If you see CPT 49505 on your bill alongside related codes, verify they are not already bundled per NCCI (National Correct Coding Initiative) edits.
What to check on your bill
Request an itemized bill and verify: (1) the CPT/HCPCS code matches the procedure actually performed, (2) the date of service is correct, (3) no duplicate line items exist for the same procedure, (4) modifier codes are appropriate (e.g., bilateral, reduced services), (5) the charge is not dramatically higher than the Medicare rate of $511, and (6) any ancillary charges (anesthesia, pathology, supplies) are reasonable and not already bundled into the primary procedure code.
Facility rate
$511
National Medicare benchmark
Non-facility rate
$99
Office setting benchmark
Data sources
4
24 data points
Key insights for CPT 49505
ASC vs hospital outpatient savings
$1,844Having this done at an ambulatory surgery center costs $1,685 vs $3,529 at a hospital outpatient
Facility vs office setting
$412 differenceNon-facility setting is less expensive for this procedure
What this procedure costs across different settings
The same procedure can cost very different amounts depending on where it's performed. These are the Medicare-allowed amounts — what hospitals actually charge can be 3-10x higher.
| Setting | Medicare rate | vs lowest |
|---|---|---|
| Facility (physician office) | $511 | +416% |
| Non-facility (office) | $99 | Lowest |
| Outpatient (APC) | $3,529 | +3465% |
| Ambulatory surgery (ASC) | $1,685 | +1602% |
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About this data
Rates shown are from the 2026 Medicare Physician Fee Schedule, Hospital Outpatient Prospective Payment System (OPPS), Ambulatory Surgery Center Payment System, Clinical Laboratory Fee Schedule, Durable Medical Equipment Fee Schedule, and CMS Inpatient Prospective Payment System (DRG weights). Regional adjustments use CMS Geographic Practice Cost Indices (GPCI). Hospital charges are from CMS Hospital Price Transparency machine-readable files. All data is publicly available under federal law (45 CFR Part 180).
This data is for informational purposes only and does not constitute medical or financial advice. Actual costs depend on insurance coverage, negotiated rates, and individual circumstances.
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Data: Federal physician fee schedules, hospital payment data, surgery center rates, lab fee schedules, and drug pricing data. FY 2024. All publicly available from federal sources.
Methodology: Facility rate applies when the procedure is performed in a hospital or ASC. Non-facility rate applies in a physician office. GPCI adjustments reflect regional cost-of-living differences.
This information is for educational purposes only and is not medical, financial, or legal advice. Actual costs depend on your insurance and provider. We recommend verifying costs directly with your provider. Full methodology · Terms of use