Commercial healthcare reimbursement in Pennsylvania
How Pennsylvania compares with the nation, by payer, specialty and procedure.
Pennsylvania at a glance
What the data shows
Pennsylvania ranks 30th of 51 states for commercial reimbursement, with an index of 96 (100 = national median) across 228 procedure codes; the Northeast region averages 107.
Commercial rates in Pennsylvania run a median 143% of Medicare.
UnitedHealthcare has the highest index in the state (115) and Aetna the lowest (82), a 33-point gap, in the files analyzed.
CPT 11104 (Punch bx skin single lesion) is the strongest relative to the national median (139% of it, a 39% premium); CPT 76512 (Oph us dx b-scan) is furthest below (73% of the national median, 27% lower).
By specialty, Pennsylvania is strongest for internal medicine (ranks 23rd of 51 states for that specialty) and weakest for ophthalmology (47th of 50).
Against Medicare, gastroenterology has the highest ratio in Pennsylvania (165% of Medicare) and dermatology the lowest (95%).
Payer ranking in Pennsylvania
| Payer | Index | Rank | Level | Codes | Providers | TINs |
|---|---|---|---|---|---|---|
| UnitedHealthcare | 115 | 1 | 228 | 751 | 498 | |
| Blue Cross Blue Shield | 101 | 2 | 228 | 564 | 630 | |
| Cigna | 94 | 3 | 227 | 788 | 594 | |
| Aetna | 82 | 4 | 228 | 679 | 611 |
Reimbursement index by specialty in Pennsylvania
| Specialty | Index | Rank among states | % of Medicare | Level | Codes | Providers |
|---|---|---|---|---|---|---|
| Internal medicine | 100 | 23 of 51 | 113% | 25 | 108 | |
| Urology | 102 | 26 of 50 | 156% | 37 | 111 | |
| Gastroenterology | 98 | 26 of 50 | 165% | 36 | 115 | |
| Orthopedic surgery | 97 | 27 of 51 | 145% | 39 | 104 | |
| Dermatology | 99 | 27 of 50 | 95% | 44 | 119 | |
| Cardiology | 98 | 29 of 51 | 150% | 38 | 98 | |
| Diagnostic radiology | 96 | 32 of 51 | 149% | 49 | 120 | |
| Ophthalmology | 84 | 47 of 50 | 98% | 42 | 117 |
Specialty by payer in Pennsylvania
| Specialty | UHC | Aetna | Cigna | BCBS |
|---|---|---|---|---|
| Internal medicine | 120 | 73 | 97 | 107 |
| Dermatology | 113 | 74 | 85 | 121 |
| Ophthalmology | 94 | 81 | 82 | 85 |
| Cardiology | 112 | 99 | 86 | 100 |
| Orthopedic surgery | 106 | 82 | 87 | 96 |
| Diagnostic radiology | 117 | 77 | 99 | 96 |
| Urology | 114 | 78 | 91 | 104 |
| Gastroenterology | 124 | 85 | 85 | 99 |
Pennsylvania compared with Northeast region states
| State | Index | Rank | % of Medicare | Providers | Level |
|---|---|---|---|---|---|
| Pennsylvania | 96 | 30 | 143% | 892 | |
| New York | 93 | 37 | 132% | 942 | |
| Rhode Island | 99 | 26 | 148% | 632 | |
| New Jersey | 100 | 22 | 154% | 887 | |
| Maine | 100 | 23 | 148% | 647 | |
| Vermont | 107 | 18 | 157% | 365 |
Procedures that pay most and least in Pennsylvania vs the nation
Highest vs national
| Code | Pennsylvania | National | Gap | Prov. |
|---|---|---|---|---|
| 11104 Punch bx skin single lesion | $112 | $81 | +39% | 119 |
| 11102 Tangntl bx skin single les | $90 | $65 | +38% | 119 |
| 11301 Shave skin lesion 0.6-1.0 cm | $101 | $85 | +20% | 117 |
| 11302 Shave skin lesion 1.1-2.0 cm | $115 | $98 | +17% | 117 |
| 17313 Mohs 1 stage t/a/l | $590 | $515 | +15% | 117 |
| 64566 Neuroeltrd stim post tibial | $77 | $69 | +12% | 111 |
| 17311 Mohs 1 stage h/n/hf/g | $634 | $577 | +10% | 117 |
| 88312 Special stains group 1 | $105 | $97 | +7% | 230 |
| 88342 Imhchem/imcytchm 1st antb | $102 | $95 | +7% | 116 |
| 51702 Insert temp bladder cath | $65 | $61 | +7% | 111 |
| 52287 Cystoscopy chemodenervation | $391 | $367 | +7% | 111 |
| 51700 Irrigation of bladder | $82 | $77 | +6% | 108 |
| 52000 Cystourethroscopy | $222 | $210 | +6% | 109 |
| 88313 Special stains group 2 | $74 | $71 | +5% | 114 |
| 97110 Therapeutic exercises | $33 | $31 | +5% | 99 |
Lowest vs national
| Code | Pennsylvania | National | Gap | Prov. |
|---|---|---|---|---|
| 76512 Oph us dx b-scan | $51 | $70 | -27% | 117 |
| 67108 Repair detached retina | $1,240 | $1,594 | -22% | 116 |
| 65855 Trabeculoplasty laser surg | $240 | $307 | -22% | 116 |
| 66984 Xcapsl ctrc rmvl w/o ecp | $582 | $738 | -21% | 116 |
| 92250 Fundus photography w/i&r | $42 | $53 | -21% | 117 |
| 67042 Vit for macular hole | $1,186 | $1,494 | -21% | 116 |
| 67036 Removal of inner eye fluid | $889 | $1,117 | -20% | 116 |
| 67028 Injection eye drug | $110 | $137 | -20% | 116 |
| 67210 Treatment of retinal lesion | $534 | $659 | -19% | 116 |
| 65778 Cover eye w/membrane | $57 | $70 | -19% | 116 |
| 66982 Xcapsl ctrc rmvl cplx wo ecp | $797 | $981 | -19% | 116 |
| 65756 Corneal trnspl endothelial | $1,170 | $1,425 | -18% | 116 |
| 66821 After cataract laser surgery | $324 | $393 | -18% | 116 |
| 15823 Blepharp upr eyelid xcsv skn | $559 | $677 | -18% | 116 |
| 92004 Compre oph exam new pt 1/> | $103 | $124 | -17% | 116 |
Frequently asked questions
How do commercial reimbursement rates in Pennsylvania compare with the rest of the country?
Pennsylvania ranks 30th of 51 states with an index of 96, across 228 procedure codes. Median commercial rates run 143% of the Medicare rate.
Which payer has the highest rates in Pennsylvania?
In the files we analyzed, UnitedHealthcare has the highest index (115) and Aetna the lowest (82). Each payer's figures describe the specific plans and networks in the files used, not its whole book of business.
Which specialty has the strongest rates in Pennsylvania?
Internal medicine ranks 23rd of 51 states.
How many providers does this Pennsylvania page cover?
892 sampled providers across 4 payers. The data comes from a random sample of providers, so counts describe the sample, not every provider in the state.
Which procedures differ most between Pennsylvania and the national median?
CPT 11104 (Punch bx skin single lesion) is highest relative to the nation at 139% of the national median; CPT 76512 (Oph us dx b-scan) is lowest at 73%.
Methodology
- Source: in-network negotiated-rate files published under the federal Transparency in Coverage rule, August 2026 snapshot: UnitedHealthcare Choice plans (74 files); Aetna commercial plans (70 files); Cigna national PPO (1 files); BCBS licensees' own-network files (5,387 files). Payer comparisons describe these files, not each payer's entire book of business.
- Sample: rates come from a random sample of up to 150 providers per state and specialty. Counts on this page are sampled providers and TINs, not totals.
- Which providers count: only providers in a specialty relevant to the code, because a rate in a payer file attaches to a provider group and is listed under every provider in that group.
- Filters: fee-for-service, professional billing class, no modifier, negotiated or fee-schedule dollar rates. Rates outside 1% to 1,000% of the Medicare rate are excluded.
- Statistic: one median rate per provider, then percentiles across providers. A cell is shown only with at least 15 sampled providers and 4 TINs.
- Medicare benchmark: CY2026 national physician fee schedule, non-QPP conversion factor, unadjusted for locality. Where the non-facility rate is more than twice the facility rate (office rates that include device or supply cost), the facility rate is used so comparisons are like for like.
Benchmark your Pennsylvania contracts
Compare your negotiated rates with these state medians by payer and specialty.