Health Costs

What's the process for calculating average total cost?

The cost data on this site comes from the State of Maine's All-Payer Claims Database (APCD) and represents claims from April 1, 2018 – March 31, 2019. CompareMaine does not include information on the uninsured or public payers Medicare and Medicaid (MaineCare). A total of 6,279,796 claims from 33 payers were analyzed.

The cost estimates on CompareMaine are median payments and are meant to serve as a reference point for comparison. MHDO makes every effort to provide accurate information on this website. Healthcare providers and insurance companies included on CompareMaine are sent the cost data to review for accuracy before they are released. Estimates published on this website are within 10% of payer and facility estimates.

Please contact your insurance company to find out your actual payment. If you do not have insurance, please contact the facility that you are most interested in for what you may be asked to pay. When contacted directly, facilities often report their charges which may be higher than the actual payments they receive from insurance companies and patients.

The Steps We Take to Find Procedure Costs

Step 1: Filter the Data

First, we filter the data by taking out entries with missing or unclear information. At this time, we also remove claims from public payers like Medicare and Medicaid and for those 65 years old or older, as these are often paid for in-part by a public payer like Medicare. Including these claims would distort the average. However, this site is still a useful tool for people ages 65 and older with commercial insurance. To protect patient privacy, we do not report a facility's ratings for a specific procedure if the facility has fewer than 5 claims for that procedure in the database:

Incomplete Encounters: Some procedures require professional and facility services. We remove patient encounters that only include either the facility or professional portion.

Encounters Without Cost Data: We remove claims that do not have cost information.

Step 2: Find Claims Linked to a Test or Service

The second step is to find the claims linked to a test or service. CompareMaine shows the average cost for a given medical test or service based on insurance claims that insurance companies are required to submit to the MHDO.

Depending on the procedure, the total cost can include:

Professional Costs: The portion of the cost paid to the healthcare provider, such as nurse, doctor or therapist, who provides direct services or procedures to a patient.

Facility Costs: The portion of the cost paid to the organization that provides healthcare services and procedures. This includes hospitals, surgical centers, diagnostic imaging centers, health centers, laboratories and clinics.

Please visit All Cost Procedures to see which costs are included in each procedure.

Step 3: Calculate the Average Cost

The third step is to compute the average cost for each test or service at each facility.

We use the median value rather than the mean to come up with the average cost. A median is the middle value when all items in a sample are sorted from lowest to highest. The mean is figured by adding up all the values and dividing by the number of items in the sample. The problem with using the mean is that it is affected by extreme values that are very high or very low compared to the rest of the sample. We believe the median is better than the mean for summarizing averages in healthcare because it represents the amount that a procedure is most likely to cost and is less likely to be influenced by extreme values.

Bundled Services

Some procedures commonly occur with another procedure so we estimate their cost together as a “bundled service.” CompareMaine has three categories of bundled services:

Bloodwork: These are bundled with the cost of the blood draw (CPT Code 36415) and transportation of the sample to a lab when necessary (CPT Code 99000).

Non-Bloodwork Labs: These labs are bundled with the cost for transportation of the sample when necessary (CPT Code 99000).

Skin Lesions: There are two skin lesion procedures on CompareMaine:

  1. Removal of Precancerous Skin (CPT Code 17000): This is bundled with the cost of the office visit in which the removal occurs (CPT Codes 99385-99386, 99395-99396, 99201-99205, 99211-99215, 99381-99384, 99391-99394, 99241-99245), the biopsy (CPT Code 88305), and the pathology exam (CPT Code 11100).
  2. Removal of Noncancerous Skin (CPT Code 17110): This is bundled with the cost of the office visit in which the removal occurs (CPT Codes 99385-99386, 99395-99396, 99201-99205, 99211-99215, 99381-99384, 99391-99394, 99241-99245).

Example: Calculating Costs for Blood Tests at Two Facilities

In this example, the costs are the same at the two labs for the first four patients' blood tests. But, Patient E's blood test costs $200 more at Lab 2 than at Lab 1. The median or middle value stayed the same at the two labs. But the mean cost for blood testing is $40 more at Lab 2 (bumped up by the more expensive testing for one patient, Patient E). The median cost, $100, is a better example of what blood testing costs.

Patient Lab 1 Costs Lab 2 Costs
Patient A's Blood Test $50 $50
Patient B's Blood Test $50 $50
Patient C's Blood Test $100 $100
Patient D's Blood Test $100 $100
Patient E's Blood Test $150 $350
Total Sum of Blood Testing $450 $650
MEDIAN Cost (middle value in list, Patient C) $100 $100
MEAN (Total Sum/Total Number of Tests) $90 $130

Some services like physical therapy (PT) or occupational therapy (OT) are measured in time increments, referred to as "units". These units typically represent 15 minutes of therapy. You may receive multiple units of different types of therapy during one appointment. For example, you may receive 30 minutes (two units) of therapeutic exercise and 15 minutes (1 unit) of ultrasound therapy. So, to estimate your cost for the entire visit, you would multiply the cost of therapeutic exercise by 2 units and the cost of ultrasound therapy by 1 unit and then add the two costs together. In the spring of 2016, we updated our reporting of PT and OT services to calculate the unit cost (for example, 15 minutes of exercise). You may receive multiple units during an appointment.

Patients often receive multiple types of treatment in a physical or occupational therapy appointment and the type of service provided may change over the course of treatment. If you have more than one therapeutic service during the same visit, you will need to look up each service separately. Your PT or OT provider can provide information about what services, including the number of units of each service, will likely be billed during your course of treatment.

When you use CompareMaine, you can filter it by a specific insurance company. If you don't choose an insurance company, the cost shown is the median cost for the test or service at the facility across all insurance companies.

Step 4: Link a Cost to a Facility

Finally, we determine which facility the cost should be assigned to. Sometimes only one facility provides a service, like an office visit with a primary care physician. But procedures may involve more than one facility. For example, if a patient has blood work done, a lab might draw the blood and another lab might test and report the results. When more than one facility provides care, the facility with the largest part of the bill is the "Lead Provider" and all costs are attributed to them.