my wife and I basically looked at a full map of the US on google maps and went through each state, trying to decide which ones we absolutely would be miserable living in. Once that as straight, then I decided to apply to all the programs in the remaining states.
I don't think anyone, even the dude with the 270 step 1, can be picky. In this month's issue of the AAMC's Careers in Medicine, they highlighted that the top 4 competitive specialities in this last match was derm, ENT, neurosurg, and ortho. We all know what a crazy hard field this is, so I think once you pick out the programs you would hate being at (at face value), then apply everywhere else. Its better to have to call programs and turn down their offers than be sweating bullets for more interviews.