How to Set Fees for a Cash-Pay Medical Practice: UCR Rates, CMS Fee Schedule, and Market Benchmarks
Cash-pay and self-pay medical practices have a paradox: you have total freedom to set your own prices, which means you bear full responsibility for setting them correctly. Price too low and you can't cover overhead. Price too high and you lose patients who are already skeptical about paying out-of-pocket. This guide walks through the three primary benchmarking tools — the CMS Physician Fee Schedule, the FAIR Health database, and UCR (Usual, Customary, and Reasonable) rate analysis — plus proven discount strategies that keep you profitable while making care accessible.
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The Quick Answer
Start by looking up your most commonly billed CPT codes on the CMS Physician Fee Schedule (cms.gov/medicare/payment/fee-schedules) for your geographic area. This gives you Medicare's reimbursement rate — your floor. For cash-pay pricing, set your standard fee at 110–150% of the Medicare rate (which is roughly what commercial insurance pays). Then offer a prompt-pay self-pay discount of 20–40% to uninsured patients, bringing your effective cash price to 80–110% of Medicare rates. Use FAIR Health Consumer (fairhealthconsumer.org) to benchmark against what private insurers pay in your zip code.
The CMS Physician Fee Schedule: Your Pricing Foundation
The CMS Physician Fee Schedule (PFS) is a publicly available database showing what Medicare pays for every CPT code, by geographic region. Access it at cms.gov/medicare/payment/fee-schedules/physician. Search any CPT code — for example, CPT 99213 (established patient office visit, moderate complexity) pays $97–$115 depending on your Medicare locality. CPT 99214 (moderate-high complexity) pays $131–$155. These are non-facility rates for office-based services. Medicare rates represent roughly 78–85% of what commercial insurers pay, so if Medicare pays $100 for a service, a commercial payer likely pays $118–$128. Setting your cash price at 120–135% of Medicare is a reasonable starting point that matches commercial payer rates while remaining competitive for self-pay patients. Print out rates for your 15 most common CPT codes — these drive 80% of your revenue.
FAIR Health Database: Regional Commercial Rate Benchmarking
FAIR Health (fairhealthconsumer.org) is a nonprofit that maintains a database of 36 billion private insurance claims. Their consumer tool lets anyone look up the typical cost range for a medical service by CPT code and zip code — showing what private insurers typically pay at the 25th, 50th, and 80th percentile of claims in your area. The physician-facing FAIR Health portal (fairhealth.org) gives more granular data. For a cash-pay practice, set your published prices near the 50th percentile of FAIR Health data — this is what a reasonably priced in-network provider would bill. Post these prices publicly on your website; the No Surprises Act (effective 2022) requires good-faith cost estimates for uninsured patients, and price transparency is increasingly a patient acquisition differentiator.
Self-Pay Discount Strategies That Work
Offering a structured self-pay discount is both legally required (you must offer uninsured patients the same access to discounted pricing as insured patients under most state laws) and good business. A standard approach: post your 'full' fee at 120% of Medicare, then offer a 25–35% prompt-pay discount for cash, card, or HSA payment at time of service. This results in an effective cash price of 78–90% of Medicare — affordable for self-pay patients and still higher than your overhead. Some practices use a sliding-scale fee structure based on income documentation (similar to FQHC models) — this expands access but adds administrative complexity. For DPC practices: your membership fee covers unlimited primary care visits; you still need a fee schedule for services outside the scope of membership (labs, imaging, procedures).
Procedure and Ancillary Service Pricing
Office procedures — joint injections, laceration repair, skin biopsies, Pap smears, IUD insertions — represent high-margin cash-pay revenue opportunities. Price these at 100–130% of Medicare non-facility rates. For example: CPT 20610 (large joint injection, e.g., knee) pays $74–$87 Medicare; a cash-pay rate of $95–$120 is reasonable. CPT 11721 (nail debridement, 6+ nails) pays $42 Medicare; cash price $55–$65. In-office labs are another revenue layer: CLIA-waived tests (strep, flu, pregnancy, urinalysis) cost $1–$8 in supplies and can be charged $15–$35 cash. Mark up CLIA-waived tests modestly to avoid antikickback scrutiny. For moderate-complexity labs requiring a CLIA certificate of compliance, ensure you have the appropriate lab license for your state before billing.
Posting Prices Publicly: The No Surprises Act and SEO Benefits
Since January 2022, the No Surprises Act requires healthcare providers to give uninsured and self-pay patients good-faith cost estimates before scheduled services. Many cash-pay practices go further and post their full fee schedule publicly — which turns a regulatory requirement into a marketing advantage. Patients searching 'how much does a [procedure] cost near me' can land directly on your fee schedule page, converting search intent to booked appointments. Several cash-pay physician networks publish price lists online: Sedera Health's partner network and the Surgery Center of Oklahoma have demonstrated that price transparency drives patient volume in cash-pay models. Build a price page on your website listing your 20–30 most common services with cash prices — it builds trust and reduces inbound 'how much does it cost' calls.
RECOMMENDED TOOLS
Tebra (Kareo)
Practice management platform with fee schedule management, CPT code tracking, and claim submission. Useful for cash-pay practices managing fee schedules and self-pay billing workflows.
FAIR Health
Nonprofit database of 36 billion insurance claims providing regional benchmarks for physician and procedure pricing by CPT code and zip code.
Hint Health
DPC membership platform with built-in pricing tools, employer plan structuring, and a network of DPC practices to benchmark membership rates in your market.
Some links above are affiliate links. We may earn a commission if you sign up — at no extra cost to you.
FREQUENTLY ASKED QUESTIONS
Am I required to post my prices publicly as a physician?
The No Surprises Act requires good-faith cost estimates for uninsured and self-pay patients upon request or before scheduled services — but does not mandate a public price list. However, hospital-based facilities have stricter price transparency requirements. For a private physician practice, posting prices publicly is not required but is a significant competitive advantage in cash-pay and DPC models.
Can I charge different prices to different patients?
Yes, with constraints. You can offer sliding-scale fees based on documented income, prompt-pay discounts, and uninsured discounts. You cannot charge Medicare or Medicaid patients more than the program's allowed amount, and you cannot offer discounts that constitute illegal inducement (e.g., waiving all copays as a policy). Many state insurance codes prohibit routinely waiving copays for insured patients without documented financial hardship.
What is a UCR rate and how is it different from the Medicare fee schedule?
UCR stands for Usual, Customary, and Reasonable. Historically, insurers set UCR rates based on the 80th or 90th percentile of what all physicians in an area charge for a given service. Today UCR databases are proprietary (Ingenix/OptumInsight maintains one). The Medicare Physician Fee Schedule is government-set based on RVUs (relative value units) and is often lower than local UCR rates. For cash-pay pricing purposes, CMS rates + FAIR Health regional data give you a more transparent and defensible benchmark than proprietary UCR databases.