What factors affect fee schedules for CPT 99213?

Factors that affect fee schedules include Medicare & Medicaid rates (government-set), private insurance rates (negotiated), geographic location (costs may be higher in urban areas), and provider type (hospital providers may have different rates than private practice).

How does CPT 99213 compare to other E/M codes?

CPT 99213 is part of the Evaluation and Management services for Office or Other Outpatient Services. It represents a moderate-complexity encounter for an established patient, typically involving more provider time and moderate medical decision-making compared to lower-level codes.

PayerPrice displays exact negotiated rates that insurers publish under federal transparency rules, providing raw data directly from insurers' files to help renegotiate managed care contracts, prospect for new business, and integrate real-time payer data into workflows.

What is a CPT code and why is it important for understanding medical costs?

A CPT (Current Procedural Terminology) code is a five-digit numerical code used by medical professionals to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations. These codes standardize the reporting of healthcare services, making it crucial for understanding and comparing the costs of different procedures across providers and payers. When you know the CPT code for a specific service, you can more accurately research its potential cost.

How can I find out the cost of a specific medical procedure or service?

To find out the cost of a specific medical procedure or service, you can use online tools designed for healthcare price transparency. For accurate and specific pricing based on your situation, it is recommended to use Payerprice's fee schedule lookup tool. This tool allows you to search with a CPT code and your specific location to get detailed cost estimates, which can vary significantly based on geographic area and provider.

What is Payerprice and how can it help me?

Payerprice is a platform that provides tools for healthcare price transparency. It helps users understand the potential costs of medical procedures and services. By using Payerprice's fee schedule lookup tool, individuals can search for specific CPT codes and locations to find estimated prices, enabling them to make more informed decisions about their healthcare and manage their medical expenses more effectively.

Why should I use Payerprice for searching medical costs instead of other sources like CMS?

While sources like CMS (Centers for Medicare & Medicaid Services) provide valuable data, their fee schedules primarily reflect Medicare reimbursement rates, which may not accurately represent the prices charged by private insurers or for privately insured patients. Payerprice, on the other hand, offers a dedicated fee schedule lookup tool that allows users to search with a CPT code and specific location, providing more relevant and personalized pricing information for a wider range of scenarios, including private insurance and self-pay options. This makes Payerprice a more comprehensive resource for specific price inquiries.

Is Payerprice free or does it cost money to use its tools?

The provided information does not specify Payerprice's pricing model. To determine if Payerprice's tools are free or if there's a cost associated with their use, it is best to visit the Payerprice website directly or contact their support. Websites offering fee schedule lookup tools may have various business models, including free basic access, subscription plans, or per-query fees.

What information do I need to use Payerprice's fee schedule lookup tool effectively?

To effectively use Payerprice's fee schedule lookup tool, you will primarily need two key pieces of information: the CPT (Current Procedural Terminology) code for the specific medical procedure or service you are interested in, and your specific geographic location (e.g., zip code or city/state). The CPT code identifies the service, and the location helps in getting localized pricing estimates, as costs can vary significantly by region.

CPT 99213 Fee Schedule

Last Verified: October 2026

Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.

Office O P Est Low 20 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of An Established Patient Which Requires A Medically Appropriate History And Or Examination And Low Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 20 Minutes Must Be Met Or Exceeded

Key Fact	Detail
Service Type	Evaluation and Management Office or Other Outpatient Services
Common Place of Service	11 - Office 20 - Urgent Care Facility
Common Modifiers	None 25 - Significant, separately identifiable E/M service same day 95 - Telemedicine - audio and video
Complexity Level	Low
Medicare Fee Schedule	View Medicare rates for 99213
Medicaid Fee Schedule	View Medicaid rates for 99213

National average reimbursement for CPT 99213 by major payers:

$91.46

$86.29

$82.03

$101.25

Compare published rates across providers.

Choose a payer to see a sample of rates for CPT 99213.

CPT 99213

5 of 25 sample ratesHigher to lower in this preview

Megan Aurora
Mass General Brigham Incorporated
MAPediatrics PhysicianNPI 1982990388Tax ID 42-807148
$271.32Published rate
Sandra Meyerson
Atrius Health, Inc.
MAPediatrics PhysicianNPI 1487634564Tax ID 43-397450
$175.16Published rate
Benjamin Boswell
University Hospitals Health System Inc
FLSports Medicine (Emergency Medicine) PhysicianNPI 1174958961Tax ID 20-4881619
$135.11Published rate
Erin Kelly
Town Center Orthopaedic Associates, P.C.
VAOccupational TherapistNPI 1285350918Tax ID 54-1383504
$104.54Published rate
Matthew Rushing
Goshen Medical Center Incorporated
NCFamily Medicine PhysicianNPI 1588010268Tax ID 56-1209062
$38.86Published rate

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Summit Women's CareDenver, Colorado

September 2, 2026

Contracting Manager
UnitedHealthcare
Commercial PPO

Re: Request for fee schedule renegotiation

We request a formal review of our Commercial PPO fee schedule. The comparison below summarizes our current rate alongside published rates for comparable Denver-area practices.

Market evidence · CPT 59485

Current rate: $152.40
Market median: $147.00
Market position: 61st percentile

The comparison includes 1,284 published rates from 96 provider groups, scoped to OB/GYN providers in a professional, office-based setting.

We would welcome a discussion of our fee schedule and the supporting July 2026 market analysis. Please let us know a suitable time to review the comparison together.

Sincerely,
Summit Women's Care

This code appears in 29 published specialty markets.

Explore state-level rates by specialty

Payer payment policies426 policies from 25 payersChecked Oct 2026

Billing CPT 99213 with a preventive visit? UnitedHealthcare, Cigna and Florida Blue pay it at 50%.

UnitedHealthcare50% paid

When a problem-oriented E/M service is billed with a preventive medicine service on the same date by the same specialty provider, UnitedHealthcare pays the preventive visit plus 50% of the E/M code if modifier 25 is appended and the E/M is significant and separately identifiable.

All states · Verified Oct 2026 · Source R0013, p. 1

Cigna50% paid

When preventive and problem-based E/M services are both performed on the same day and the policy criteria are met, the preventive service is paid at 100% and the problem-based E/M service is paid at 50%.

All states · Verified Oct 2026 · Source R02, p. 2

Florida Blue50% paid

When a significant separately identifiable problem-oriented E/M service is billed with a preventive medicine E/M service on the same day, the problem-oriented E/M is paid at 50% of its amount.

FL · Verified Oct 2026 · Source 10_016, p. 1

36 payment rules from 13 payers apply to CPT 99213

Modifier requirements17 rules · 8 payers
Reduced payment13 rules · 9 payers
Bundled with other services3 rules · 2 payers
Unit and frequency limits3 rules · 2 payers

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Summaries by PayerPrice from payers' published policies, re-checked monthly. Not coding or legal advice.

CPT 99213 vs. Other Office or Other Outpatient Services Codes

The CPT 99213 code is part of the Evaluation and Management services used for Office or Other Outpatient Services. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.

The CPT 99213 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.

Code	Complexity	Description
99202-CPT	Low	Office O P New Sf 15 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of A New Patient Which Requires A Medically Appropriate History And Or Examination And Straightforward Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 15 Minutes Must Be Met Or Exceeded
99211-CPT	Low	Office Or Other Outpatient Visit For The Evaluation And Management Of An Established Patient, That May Not Require The Presence Of A Physician Or Other Qualified Health Care Professional. Usually, The Presenting Problem(S) Are Minimal.
99212-CPT	Low	Office O P Est Sf 10 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of An Established Patient Which Requires A Medically Appropriate History And Or Examination And Straightforward Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 10 Minutes Must Be Met Or Exceeded
99213-CPT	Low	Office O P Est Low 20 Min, Office Or Other Outpatient Visit For The Evaluation And Management Of An Established Patient Which Requires A Medically Appropriate History And Or Examination And Low Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 20 Minutes Must Be Met Or Exceeded

What is a fee schedule?

A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99213. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.

Understanding the 99213 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.

Factors that affect fee schedules

Medicare & Medicaid Rates

Government-set reimbursement amounts

Private Insurance Rates

Negotiated rates between providers and insurance companies

Geographic Location

Costs may be higher in urban areas.

Provider Type

Hospital providers may have different rates than private practice.

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CPT 99213 Fee Schedule

Megan Aurora

Sandra Meyerson

Benjamin Boswell

Erin Kelly

Matthew Rushing