Objectives To investigate the degree to which expenditures on symptom evaluations vary among urologists and the factors associated with such variation. As the medical and surgical specialists for men with lower urinary tract symptoms (LUTS), urologists provide testing to evaluate symptoms and determine therapy. Methods We developed a cohort of men with an initial urologist visit for benign prostatic hyperplasia (BPH) from a 5% sample of Medicare patients (1999-2007) and established a physician level factor, practice style, as a function of average per patient expenditures. We then determined which AUA BPH guideline elements explained variation in quantity and expenditures for BPH testing, and also examined the impact of patient and physician factors on practice style. Results A nearly 15-fold variation in urologists' average per-patient expenditures existed ($35 to $527 per month; Median $92). Practice styles were associated with physician (P < .01 all examined variables) and patient (P < .01 for comorbidity, race/ethnicity, and socioeconomic status) factors. Guideline recommended care was provided at lower rates by the lowest expenditure urologists compared with middle- to highest-intensity urologists (P < .01). Practice style variations were attributable mainly to differences in tests characterized by the guidelines as optional and not-recommended (P < .01). Conclusions Expenditures for BPH evaluations vary substantially by geography, practice setting, and experience and are accounted for largely by differences in the use of optional and not-routinely recommended tests. Greater standardization could enhance patient care and reduce health care costs.