CPT Fee Schedule & Reimbursement Gap Benchmarker
Are outdated payer fee schedules quietly eroding your clinical earnings? Benchmark your top procedure codes against 2026 Medicare allowable rates and 135%–160% commercial PPO rates to quantify your underpayment gap.
CPT Fee Schedule & Reimbursement Gap Calculator
Explore sample reimbursement scenarios. These preset rates are illustrative, not verified CMS rates or contract benchmarks. Use your actual locality, date of service, facility setting and signed fee schedule to assess payment differences.
Approx. $14,835/month left uncollected due to outdated commercial payer fee schedule allowances.
| CPT Code | Service Description | Illustrative Base Allowable | Commercial Typical (135%) | Top PPO Benchmark (160%) |
|---|---|---|---|---|
| 99213 | Office visit, established, level 3 (low) | $91.50 | $125.00 | $148.00 |
| 99214 | Office visit, established, level 4 (moderate) | $130.80 | $178.00 | $210.00 |
| 99215 | Office visit, established, level 5 (high) | $184.20 | $252.00 | $298.00 |
| 99396 | Preventive exam, established (40-64 yrs) | $145.00 | $195.00 | $235.00 |
| 99490 | Chronic care management (CCM), 20 min | $62.40 | $85.00 | $98.00 |
*Medicare allowable rates reflect 2026 CMS Physician Fee Schedule (MPFS) non-facility national conversion factor averages. Commercial benchmark percentiles reflect proprietary multi-payer aggregated adjudication data across Aetna, BCBS, Cigna, and UHC.
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