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Are outdated payer fee schedules quietly eroding your clinical earnings?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 $14,835/month left uncollected due to outdated commercial payer fee schedule allowances.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.
Turn these Fee Schedule Benchmarker insights into a practice-specific review
Want Aethera to renegotiate your commercial payer contracts? Our payer contracting specialists review your top 50 codes and demand rate parity with top regional health systems. Let our senior AAPC-certified billing team audit 50 of your active claims or past denials — completely free. Results in 14 days after the BAA, complete intake and agreed success criteria.
Test our scrub rules and appeal workflow on 50 real claims. Zero commitment, no credit card required.
Enter your aging totals for an instant planning report. Uploaded files are processed locally; clinical intake is arranged separately.