This cross-sectional study uses Medicare service and payment data to identify and quantify disparity by gender among neurosurgeons serving the fee-for-service population.
Key Points
Question
Is there variation in reimbursements to neurosurgeons based on gender?
Findings
In this cross-sectional study of 6052 neurosurgeons providing care to Medicare fee-for-service patients between 2013 and 2020, women received significantly lower annual mean reimbursement even after controlling for metrics of practice volume. Women were also reimbursed less per service even after matching by Common Procedural Terminology code.
Meaning
These findings suggest that differences in practice composition and billing and coding practices, such as the use of modifiers, may drive the gender disparities in payment.
Abstract
Importance
Despite efforts to promote diversity within the neurosurgical workforce, individuals from underrepresented groups face significant challenges.
Objective
To compare practice metrics and earning potential between female and male neurosurgeons and investigate factors associated with gender disparity in Medicare reimbursement.
Design, Setting, and Participants
This retrospective cross-sectional study used publicly accessible Medicare data on reimbursements to female and male neurosurgeons for procedural and evaluation and management services delivered in both inpatient and outpatient settings between January 1, 2013, and December 31, 2020. Data were analyzed from December 9, 2021, to December 5, 2022.
Main Outcomes and Measures
The primary outcome was the mean annual payments received and charges submitted by female and male neurosurgeons for services rendered between 2013 and 2020. Secondary outcomes included the total number and types of services rendered each year and the number of beneficiaries treated. Univariate and multivariable analyses quantified differences in payment, practice volume, and composition.
Results
A total of 6052 neurosurgeons (5540 men [91.54%]; 512 women [8.46%]) served the Medicare fee-for-service patient population. Female neurosurgeons billed for lesser Medicare charges (mean [SE], $395 851.62 [$19 449.39] vs $766 006.80 [$11 751.66]; P < .001) and were reimbursed substantially less (mean [SE], $69 520.89 [$2701.30] vs $124 324.64 [$1467.93]; P < .001). Multivariable regression controlling for practice volume metrics revealed a persistent reimbursement gap (−$24 885.29 [95% CI, −$27 964.72 to −$21 805.85]; P < .001). Females were reimbursed $24.61 less per service than males even after matching services by code (P = .02).
Conclusions and Relevance
This study found significant gender-based variation in practice patterns and reimbursement among neurosurgeons serving the Medicare fee-for-service population. Female surgeons were reimbursed less than male surgeons when both performed the same primary procedure. Lower mean reimbursement per service may represent divergence in billing and coding practices among females and males that could be the focus of future research or educational initiatives.
Introduction
Limited representation of women in surgical subspecialties, including neurosurgery, presents an essential obstacle to workforce diversification by reinforcing the perception of gender inequality.1 In evidence of this, females account for approximately 50% of medical school graduates but comprise just 18.2% of neurosurgery residents, 8.7% of academic faculty,2 and only 6% of board-certified neurosurgeons.3 In the US, female physicians are estimated to be compensated 25% less, or the equivalent of $2 million in career-long earnings.4 This is especially evident in procedural specialties, where women are most underrepresented.5 Factors such as age, location, specialty, rank, hours worked, and research output have all been cited as possible causes.4,5 Indeed, in neurosurgery, females tend to be more junior, underrepresented in higher academic ranks and leadership, and have lower research output metrics.6,7,8 Pay disparities persist across the medical field even after controlling for these variables.9,10,11,12
While concerted efforts to increase representation of women in neurosurgery are ongoing, there has been little exploration of gender-based pay disparity in the field. One recent analysis6 concluded that gender was not associated with pay disparity; instead, pay disparity was associated with academic rank. However, that analysis was limited to public institutions within states that mandate reporting of employee salaries and, therefore, cannot be generalized to other settings. Obtaining consistent and reliable data to identify gender-based pay disparities across diverse practice settings is challenging; many studies4,13,14 have relied on self-reported surveys that can introduce subject-to-subject inconsistency. While the total take-home pay, wage, or salary of a physician may derive from various sources, the component derived from fee-for-service reimbursement of services rendered remains a substantial portion that can be studied. Medicare data sets present an opportunity to explore gender-related pay disparity within a limited but detailed stream of physician income.12,15,16,17,18 Moreover, because clinicians widely accept Medicare in academic and private practice, insights from these data are applicable across practice settings. For these reasons, we used Medicare service and payment data to identify and quantify gender-based pay disparity among neurosurgeons serving the fee-for-service population. Identifying challenges that female neurosurgeons face will provide areas for future inquiry and opportunities for improved equity to aid in recruiting and retaining this vital workforce.
Methods
Data Source
This cross-sectional study analyzed publicly available Centers for Medicare & Medicaid Services (CMS) Medicare Fee-for-Service Provider Utilization and Payment Data from January 1, 2013, to December 31, 2020.19 Provider Summary files, organized by National Provider Identifier (NPI), summarize individual clinician’s demographics (geographic location and gender) and annual services to the Medicare fee-for-service population, including the number of total and unique services, number of beneficiaries, submitted charges, and payments received. Detailed data files are organized by NPI and Current Procedural Terminology (CPT) codes and provide an itemized assessment of a clinician’s annual practice composition, volume, and associated payment. Both data sets only include claims submitted for services to traditional Medicare beneficiaries, excluding Medicare Advantage enrollees. In addition, physicians with 10 or fewer services were excluded to protect patient privacy. Medical school graduation year was obtained from the Doctors and Clinicians National Downloadable File and linked to the primary data sets via NPI.20 All data are publicly available and do not represent individual patient data; this study was self-certified as nonhuman subject research by the Rutgers institutional review board and did not require informed consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Study Cohort
All neurosurgeons submitting at least 11 annual claims for services to Medicare fee-for-service enrollees between January 1, 2013, and December 31, 2020, were included. Individuals were grouped as female or male based on the self-reported Rendering Provider Gender field. Nonphysicians were excluded from the cohort by filtering for MD, DO, or equivalent credentials.
Study Variables
Primary end points for this study were annual total submitted charges, payments, mean charge per service, and mean payment per service in US dollars. All monetary values were adjusted for inflation to 2020 using the Consumer Price Index.21 Geographic practice cost indices (GPCIs) for each Medicare locality were sourced from CMS-established values. Other variables were used to compare practice volume and diversity, including numbers and types of services rendered, unique billing codes used, and beneficiaries treated. Finally, time in practice was estimated using medical school graduation year.
Statistical Analysis
Data were analyzed from December 9, 2021, to December 5, 2022. Descriptive statistics, including mean (SE) and median (IQR), were calculated for parametric (ie, charges, payments) and nonparametric (ie, number of services, beneficiaries, and codes) data, respectively. Differences were compared between female and male neurosurgeons using t (parametric) or Mann-Whitney Wilcoxon (nonparametric) tests. A primary sensitivity analysis excluding the highest and lowest 2.5% of earners was performed to assess the influence of outliers. Trendline analysis using Pearson linear regression assessed the significance of time trends across the study period. Multivariable linear regression was performed to evaluate the association of gender with payments, number of services and beneficiaries, and years in practice. In addition, a secondary sensitivity analysis was performed by comparing a random cohort of female and male neurosurgeons matched by total services, beneficiaries, and years in practice.
Detailed data were analyzed to identify gender variations in practice composition. Services were categorized by CPT code according to the Restructured Berenson-Eggers Type of Service Classification System (RBCS). The RBCS provides a hierarchical taxonomy for grouping procedure codes into clinically meaningful categories, including Evaluation and Management (E&M) and Procedures.22 The proportion of each category accounting for female and male neurosurgeons’ total services was calculated and compared via Pearson χ2 test. CPT codes were matched between females and males to identify differences within individual services and were compared via t test. Statistical analysis was performed using R, version 4.2.2 (R Program for Statistical Computing). Two-sided P < .05 indicated statistical significance.
Results
Population of Neurosurgeons Receiving CMS Payments From 2013 to 2020
A total of 6052 neurosurgeons were included, of whom 5540 (91.54%) were men and 512 (8.46%) were women. The number of neurosurgeons serving the Medicare fee-for-service population increased significantly from 4361 in 2013 to 4897 in 2020 (12.29%; R2 = 0.984; P < .001). In addition, there was a significant increase in females from 268 in 2013 to 408 in 2020 (52.24%; R2 = 0.994; P < .001).
Gender-Based Differences in Charges, Payments, and Practice Volume
After adjustment for inflation, female neurosurgeons submitted 48.32% less in annual Medicare charges (mean [SE], $395 851.62 [$19 449.39] vs $766 006.80 [$11 751.66]; P < .001) (Figure 1A) and received 44.08% less in annual payments (mean [SE], $69 520.89 [$2701.30] vs $124 324.64 [$1467.93]; P < .001) (Figure 1B). This disparity persisted after excluding the top and bottom 2.5% of earners (Figure 1C and D). To assess the association between gender and practice volume, the total number of annual services rendered, beneficiaries treated, and unique service codes used were compared. Consistent with charge and payment data, females billed fewer mean total services (244.5 [IQR, 126.75-461.75] vs 418.5 [IQR, 214.00-712.63]; P < .001), beneficiaries (111.0 [IQR, 60.88-191.13] vs 172.0 [IQR, 93.00-269.00]; P < .001), and unique service codes (36.0 [IQR, 22.38-50.00] vs 47.0 [IQR, 31.00-62.50]; P < .001) (eFigure 1 in Supplement 1). Moreover, the mean (SE) payment per service was 11.40% less for females than for males ($217.65 [$4.22] vs $245.65 [$1.39]; P < .001) (Table 1). Notably, females tended to have fewer years in practice, as evidenced by a more recent median graduation year (2004 vs 1997; P < .001) (eFigure 1 in Supplement 1).
Figure 1. Overall Medicare Charges and Payments by Gender.
C and D, Sensitivity analysis was performed after removing the top and bottom 2.5% of earners. Error bars indicate SEs.
aP < .001, unpaired t test.
Table 1. Medicare Charges, Payments, and Practice Volume Metrics by Gender From 2013 to 2020.
| Variable | Females (n = 512) | Males (n = 5540) | P value |
|---|---|---|---|
| Charges and payments, mean (SE)a | |||
| Total submitted charges, $ | 395 851.62 (19 449.39) | 766 006.80 (11 751.66) | <.001 |
| Total payments, $ | 69 520.89 (2701.30) | 124 324.64 (1467.93) | <.001 |
| Total standardized payments, $b | 70 175.96 (2786.81) | 125 679.52 (1492.12) | <.001 |
| Payment-to-charge ratio | 0.24 (0.005) | 0.22 (0.002) | .006 |
| Charge per service, $ | 1307.17 (54.39) | 1572.66 (19.22) | <.001 |
| Payment per service, $ | 217.65 (4.22) | 245.65 (1.39) | <.001 |
| Geographic practice cost indexc | 1.021 (0.002) | 1.020 (0.000) | .14 |
| Practice volume, median (IQR) | |||
| Total services, No. | 244.5 (126.75-461.75) | 418.5 (214.00-712.63) | <.001 |
| Unique codes, No. | 36.0 (22.38-50.00) | 47.0 (31.00-62.50) | <.001 |
| Total beneficiaries, No. | 111.0 (60.88-191.13) | 172.0 (93.00-269.00) | <.001 |
| Beneficiary risk score, mean (SE)d | 1.575 (0.452) | 1.466 (0.411) | <.001 |
Adjusted by Consumer Price Index.
Standardized payment removes adjustments for geographic differences.
Indicates payment adjustment for local costs of providing care.
Indicates payment adjustment for differences in patient risk profiles.
Univariate analyses revealed a significant association between gender and charges, payments, practice volume, and years in practice. Therefore, multivariable linear regression was performed to isolate the association of gender with total annual payment while controlling for volume and experience. There was a persistent disparity in payment, with women receiving $24 885.29 less than men (95% CI, −$27 964.72 to −$21 805.85; P < .001) (Figure 2). This was consistent with the secondary sensitivity analysis using a cohort matched by the number of services, beneficiaries, and years in practice (eTable 1 in Supplement 1).
Figure 2. Multivariable Analysis of Total Payment by Gender, Number of Services, and Years in Practice.
Gender-Based Differences in Practice Composition
Services were categorized into payment quartiles based on each CPT code’s corresponding national mean Medicare allowed amount. The detailed dataset used to study practice composition included 5356 males and 483 females who performed 11 or more identically coded services. While 4043 male neurosurgeons (75.49%) performed at least 11 annual services reimbursed at a rate above the mean of $313.65, 261 female neurosurgeons (54.04%) achieved the same (χ2 = 104.07; P < .001). In aggregate, the most highly paying services (quartile 4) accounted for 6.53% of all services performed by female neurosurgeons vs 11.40% of those served by male neurosurgeons (P < .001) (eTable 2 in the Supplement). Overall, men performed a larger proportion of more highly reimbursed services (eFigure 2 in Supplement 1). Female neurosurgeons performed a slightly larger proportion of services in the outpatient setting (61.47% vs 60.10%; P < .001) and were paid more for these services ($84.49 vs $79.05; P < .001).
We classified and summed each physician’s unique Healthcare Common Procedure Coding System codes according to RBCS taxonomy to compare the types of services performed by females and males. Men performed a larger proportion of procedures categorized as imaging (7.96% vs 5.77%; P < .001) and procedural (39.94% vs 25.40%; P < .001). In contrast, women were overrepresented in services categorized as E&M (63.86% vs 49.81%; P < .001) (eTable 2 in Supplement 1). Notably, the proportion of services coded as E&M had a weak but significant inverse correlation with years in practice (R2 = 0.243; P < .001). Finally, we assessed the top 10 most common procedural services for females and males according to the total number of services rendered during the study period and compared their national mean Medicare-allowed amounts. The top 10 most common procedures for female neurosurgeons comprised 52.80% of their aggregate procedural volume. The sum of the quantities allowed for these 10 codes was $6131.10, or $116.12 per 1%. In contrast, the top 10 most common procedures for male neurosurgeons represented 58.96% of the procedural volume with an allowed amount sum of $8531.80 ($144.70 per 1%) (eTable 3 in Supplement 1).
Potential Differences in Billing and Coding Practices of Male and Female Neurosurgeons
All procedural services were matched by CPT code, and the difference in mean submitted charge and payment per service was calculated. Compared with male neurosurgeons, female neurosurgeons submitted (−$497.22; P = .003) and were paid (−$24.61; P = .02) significantly less per service (Table 2). The largest disparities in payment existed for percutaneous vertebroplasty and vertebral augmentation procedures (codes 22513-22515) (Table 2). Even after limiting the analysis to a single year (2020), there was a persistent difference, with female neurosurgeons being paid $40.26 less per service than male neurosurgeons (P = .03). Moreover, despite variability in geographic distribution (eFigure 3 and eTable 4 in Supplement 1), there was no significant difference in GPCIs (females, 1.021; males, 1.020; P = .14). The gender disparity was still present in mean (SE) standardized Medicare payments in which GPCI adjustments were removed ($70 175.96 [$2786.81] vs $125 679.52 [$1492.12]; P < .001) (Table 1).
Table 2. Gender Variation in Payment and Charges Within Matched Procedures.
| Procedure | Mean (SE), $ | Difference, $a | |
|---|---|---|---|
| Females | Males | ||
| All | |||
| Charges | 2938.63 (238.41) | 3435.85 (282.43) | −497.22b |
| Payments | 442.26 (38.14) | 466.87 (38.32) | −24.61c |
| Largest varying, CPT code (name)d | |||
| 22513 (Percutaneous vertebroplasty) | 424.83 (6.65) | 1090.42 (75.61) | −610.80 |
| 22514 (Percutaneous vertebroplasty) | 393.10 (9.13) | 995.56 (64.98) | −565.98 |
| 22515 (Percutaneous vertebroplasty) | 177.73 (1.99) | 754.50 (85.98) | −557.86 |
| 0398T (Stereotactic cranial ablation) | 720.48 (381.33) | 1295.68 (187.76) | −247.48 |
| 63042 (Posterior laminotomy or laminectomy) | 555.88 (274.07) | 1078.79 (13.10) | −238.99 |
| 22533 (Lateral arthrodesis, extracavitary) | 738.11 (0) | 1103.29 (48.55) | −186.73 |
| 27280 (Arthrodesis, sacroiliac) | 718.84 (0) | 1030.44 (29.16) | −177.18 |
| 63267 (Spine reservoir or pump implant) | 721.97 (90.53) | 969.45 (12.36) | −175.34 |
| 22524 (Vertebroplasty) | 409.19 (11.34) | 651.13 (65.20) | −162.57 |
| 27279 (Arthrodesis, sacroiliac) | 339.64 (82.02) | 561.16 (10.56) | −154.38 |
Abbreviation: CPT, Current Procedural Terminology.
Differences in submitted charges and payments for all procedural services matched by CPT code.
P = .003 by paired t test.
P = .02 by paired t test.
Top 10 services with largest discrepancy in mean payment between males and females.
Discussion
Despite increased representation, women may face numerous challenges to surgical career progression, including inequitable hiring and promotion, bullying, harassment, and disparate compensation.23,24,25 The wage gap referencing lesser payment to women has been well described across specialties,9,10,11 including primary care,26 radiation oncology,18 cardiology,16 ophthalmology,17 and otolaryngology.15 In this study, we found the first evidence, to our knowledge, for gender-based disparity in practice characteristics and compensation to female neurosurgeons serving the Medicare population and provided insight into potential factors associated with these disparities.
Female neurosurgeons collected 44.8% less annually from Medicare than their male counterparts. The discrepancy in compensation corresponded to significant variations in practice volume, including fewer services rendered, individual patients treated, and unique services rendered. While volume was an apparent driver of this discrepancy, our multivariable regression demonstrated that this volume and procedure mix alone cannot explain the observed pay gap. When controlling for the number of services, patients, and years in practice, women were still reimbursed $24 885.29 less than men. Given the finding that practice volume only accounted for 54.59% of the quantified disparity, we sought to evaluate the influence of practice composition by comparing the numbers and types of services rendered by female and male neurosurgeons. The fewer unique services rendered by female neurosurgeons is consistent with a more limited, less diverse scope of practice. Similar results have been described based on billing data from otolaryngologists,15 cardiologists,16 and ophthalmologists.17 These findings may reflect the higher rate of subspecialty fellowship training reported among female neurosurgeons, particularly within pediatrics, oncology, spine, and trauma and critical care.3,27 Examining the types of services in the aggregate, there was a trend of female neurosurgeons performing fewer highly reimbursed services, including procedures and diagnostic imaging tests. Notably, codes classified as E&M accounted for a significantly higher proportion of those billed by female neurosurgeons, although this declined with increasing years of practice. Together with the fewer unique patients seen annually and a larger proportion of outpatient services, these data are consistent with previous literature demonstrating that female physicians spend more time per patient examining and documenting.26,28,29 The data may also reflect lower referral rates to female surgeons30 or an increased likelihood of seeing and/or opting for nonoperative management.
Our analysis demonstrated a disparity in compensation between females and males even after matching identical procedural service codes. This discrepancy could not be explained by differences in work-related geographic practice cost indices, which are multipliers used by the CMS to adjust allowed amounts based on geographic variation in costs of providing services and maintaining a clinical practice.31 Similarly, the influence of year-to-year variation in conversion factors was excluded by observing a persistent difference in payment after selecting for an individual year (2020). The absence of differences in these 2 variables that determine Medicare-allowed amounts suggests that variability in billing and coding practices may contribute to lower compensation for women. The data set used in this analysis did not allow for testing of this hypothesis, as add-on codes and modifiers are not captured. However, the theory is supported by evidence of gender differences in operative coding among plastic surgeons, including using fewer codes per case.32 Although we could not determine coding differences from the current data set, women might be less likely to use codes that reflect greater complexity, technical difficulty, patient severity, or work intensity, such as modifier 22. We are not aware of a data set that would allow an analysis of the systematic use of modifier 22, but modifier 22 is rarely used systematically enough to fully explain the aforementioned findings.33 A tendency to use codes reflecting less complexity for a given procedure might indicate a gendered approach to valuing one’s work. This would be consistent with substantial literature indicating that women underestimate their value in workplace negotiations and other professional settings.34,35
While future analysis is necessary and warranted to validate gender-based discrepancies in coding, this area is targetable through short-term educational interventions and longitudinal mentorship. Billing and coding can be incorporated into residency education as described in the University of Florida’s Transition to Practice Program.36 The American Association of Neurological Surgeons and Congress of Neurological Surgeons offer numerous coding courses that can be valuable resources for both young neurosurgeons entering independent practice and administrative staff.37
Another potential etiology for poorer reimbursement for women is that they are more likely to be marginalized within the neurosurgical community.38 Lack of peer support may contribute to decreased leverage within a hospital community through less opportune block time, less administrative support, and ultimately reduced capacity for interaction and negotiation with public or private payers. Finally, it is essential to note that this analysis only studied Medicare data. In a physician’s typical payer mix, this represents only a subset of the average physician’s payment collections, that is, between 20% and 30%, depending on the physician’s specialty and practice.39,40 Future research should evaluate whether this trend exists with private payers because the reimbursement discrepancy between female and male neurosurgeons may be further exacerbated if such patterns exist.
Limitations
This study has limitations. Actual take-home compensation, wages, and salary may be subject to variable benchmarks, metrics, and contractual arrangements (eg, work relative value unit productivity metrics). The Medicare data set is instrumental because it allows the exploration of billing differences in a controlled and cleaned data set, reflecting an environment where base prices are established and regulated according to the physician fee schedule. Therefore, deviations from anticipated compensation amounts are readily appreciable when controlling for the number and types of services. There are, however, considerable limitations to any large, administrative data set like this one. First, this data set only captures physicians who have performed at least 11 services for traditional Medicare beneficiaries. While most neurosurgeons accept Medicare,41 we may have excluded a potentially substantial portion of neurosurgeons, including those who limit the number of Medicare patients and fall under the volume threshold. Moreover, the nature of Medicare’s services is such that we likely excluded pediatric subspecialists, of whom approximately 30% are female.3,42 It is, therefore, possible that disparity in the number of services and beneficiaries reflects differences in the types of patients treated by female neurosurgeons. However, this cannot explain the persistence of the pay disparity evident on a per-service basis and after controlling for practice volume. Additionally, we cannot discount the possibility of this data set including a small number of training neurosurgeons, of whom females may account for a higher proportion. Despite these limitations, we believe our results are relevant to broader surgical practice, particularly given the large proportion of physicians who treat Medicare beneficiaries. Finally, the link between the different steps of the revenue cycle from providing a procedural service, the description of the work performed in the operative note, and its coding, charge, and eventual capture in collection or payment was not studied, as we, by the nature of the data set considered, were able to focus only on the link between charges and collections. Individual surgeon’s performing a variable amount of the coding work with partial or complete support from professional coding staff is a hidden variable that is difficult to quantify.
Conclusions
While there has been a trend of increased female representation in neurosurgery, women continue to face challenges in establishing, maintaining, and progressing within their neurosurgical careers.1,2,3 This cross-sectional study demonstrated financial disparities experienced by female neurosurgeons, including lower measures of practice volume and lesser compensation. Two potential areas for intervention and mentorship of female neurosurgeons are establishment and growth of a productive practice and use of optimal billing and coding practices that are accurate yet ensure maximal compensation. These interventions will rely on the increased recruitment and retention of women in neurosurgery, particularly in leadership and policy roles, in addition to the activism and advocacy of their male colleagues. Ultimately, the field as a whole can only benefit from all of its clinicians being appropriately compensated for their work.
eFigure 1. Overall Medicare Practice Metrics by Gender
eFigure 2. Density Plot of Mean Allowed Amount and Number of Services by Gender
eFigure 3. Distribution of Female Neurosurgeons by State
eTable 1. Medicare Charges, Payments, and Practice Volume Metrics by Gender in a Randomly Selected Matched Cohort
eTable 2. Types of Services Provided to Medicare Fee-for-Services Beneficiaries by Female and Male Neurosurgeons from 2013 to 2020
eTable 3. Top 10 Procedural Codes Utilized by Male and Female Neurosurgeons According to Total Number of Services
eTable 4. State-By-State Distribution of Female Neurosurgeons by Percentage of Total
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eFigure 1. Overall Medicare Practice Metrics by Gender
eFigure 2. Density Plot of Mean Allowed Amount and Number of Services by Gender
eFigure 3. Distribution of Female Neurosurgeons by State
eTable 1. Medicare Charges, Payments, and Practice Volume Metrics by Gender in a Randomly Selected Matched Cohort
eTable 2. Types of Services Provided to Medicare Fee-for-Services Beneficiaries by Female and Male Neurosurgeons from 2013 to 2020
eTable 3. Top 10 Procedural Codes Utilized by Male and Female Neurosurgeons According to Total Number of Services
eTable 4. State-By-State Distribution of Female Neurosurgeons by Percentage of Total
Data Sharing Statement
