Assessment Of Emotional Or Behavioral Problems
What Medicare pays for 96127, what providers bill, and how the price varies across 53 states, drawn from CMS 2023 claims data.
96127 · the short answer
For assessment of emotional or behavioral problems, Medicare pays about $3.30 on average across 53 states. This is a low-payment administrative or drug code, so the billed-to-paid ratio is not a meaningful "markup."
- Medicare pays
- $3.30
- Providers bill
- $21.69
- States with data
- 53
Medicare amounts are CMS-published; markup = average submitted charge ÷ average Medicare payment.
Price Range Across States
What You Might Pay
Estimated using RAND 2024 commercial-to-Medicare ratios. Actual prices vary by insurer, plan, and facility.
How we estimate these prices
These estimates are based on the RAND Hospital Price Transparency Study (4th Edition, 2024), which found that commercial insurance prices average 224% of Medicare rates nationally. We apply category-specific ratios: Medicine procedures average 2.15x Medicare rates. Cash/self-pay estimates blend typical cash discounts (55% of billed charges) with Medicare-based estimates (150% of allowed amounts). These are statistical estimates, not quotes. Contact your insurer or provider for actual costs.
Prices by State
| State | Medicare Payment | Billed Charge |
|---|---|---|
| Guam | $4.02 | $14.40 |
| California | $3.87 | $20.63 |
| New York | $3.85 | $29.47 |
| New Jersey | $3.79 | $18.83 |
| District of Columbia | $3.78 | $22.69 |
| Connecticut | $3.62 | $28.17 |
| Pennsylvania | $3.59 | $27.76 |
| Maryland | $3.52 | $19.27 |
| Delaware | $3.49 | $44.04 |
| Alaska | $3.48 | $25.52 |
| Massachusetts | $3.46 | $27.58 |
| Florida | $3.42 | $17.25 |
| Nevada | $3.39 | $22.88 |
| Colorado | $3.37 | $20.34 |
| Virginia | $3.36 | $18.13 |
| Illinois | $3.35 | $24.56 |
| Hawaii | $3.35 | $15.88 |
| New Hampshire | $3.33 | $18.28 |
| Washington | $3.26 | $16.70 |
| Rhode Island | $3.26 | $13.14 |
| North Dakota | $3.23 | $12.11 |
| Oregon | $3.23 | $19.23 |
| Montana | $3.16 | $14.44 |
| Texas | $3.15 | $23.84 |
| Minnesota | $3.10 | $27.81 |
| Arizona | $3.08 | $14.76 |
| Michigan | $3.08 | $16.26 |
| South Dakota | $3.07 | $24.17 |
| Georgia | $3.06 | $24.19 |
| South Carolina | $3.04 | $11.86 |
| Utah | $3.02 | $19.67 |
| Maine | $3.00 | $20.28 |
| Louisiana | $2.99 | $17.78 |
| North Carolina | $2.97 | $15.34 |
| Oklahoma | $2.91 | $12.61 |
| Wisconsin | $2.90 | $25.93 |
| Wyoming | $2.89 | $23.28 |
| Iowa | $2.89 | $43.78 |
| New Mexico | $2.88 | $20.62 |
| Tennessee | $2.88 | $13.95 |
| Alabama | $2.85 | $9.99 |
| Vermont | $2.82 | $22.51 |
| Indiana | $2.81 | $15.16 |
| Ohio | $2.79 | $14.72 |
| Missouri | $2.79 | $23.55 |
| West Virginia | $2.74 | $14.28 |
| Kentucky | $2.74 | $21.06 |
| Kansas | $2.71 | $18.37 |
| Arkansas | $2.70 | $18.02 |
| Mississippi | $2.70 | $14.21 |
| Idaho | $2.62 | $13.61 |
| Nebraska | $2.34 | $22.68 |
| Puerto Rico | $2.14 | $8.14 |
What the Data Says About Assessment Of Emotional Or Behavioral Problems
Across 53 states with reporting providers, CPT code 96127 (Assessment Of Emotional Or Behavioral Problems) shows a national average Medicare payment of $3.30 against an average billed charge of $21.69. That gap, a 6.6x markup, or 557% above the Medicare allowed amount, is not a meaningful ratio for this low-payment code, so treat the billed figure as a chargemaster reference point rather than a real-world price.
Medicine procedures like this one saw 746.1K services billed to Medicare in 2023 by 31.6K distinct providers, serving 394.5K unique beneficiaries. State-level variation is significant: Puerto Rico reports the lowest average payment at $2.14, while Guam reports the highest at $4.02. A 87% spread this wide is typically a GPCI story: practice-expense and malpractice-premium components of the fee formula diverge sharply by locality even though the procedure code never changes.
Applying RAND 2024 commercial-to-Medicare ratios specific to the Medicine category (2.15x), the estimated commercial insurance price lands near $10.00, with self-pay cash discounts commonly bringing the figure closer to $9.45. Within Medicine, Assessment Of Emotional Or Behavioral Problems ranks #519 of 533 tracked procedures by national average Medicare payment.
What to do with this
If you may have assessment of emotional or behavioral problems done, these steps turn the numbers above into a real-world cost estimate.
- Request a Good Faith Estimate from your provider at least 3 business days before a scheduled procedure, under the No Surprises Act it is an enforceable written price.
- Compare assessment of emotional or behavioral problems costs in your state, Medicare rates vary by locality. Browse states
- Check a hospital’s published cash price, which is often far below the billed charge. Price transparency
- Understand why billed charges run several times the Medicare rate before you negotiate. Read the guide
Figures here are averages and estimates, not a quote. Confirm coverage and out-of-pocket costs with your insurer and provider.
Frequently Asked Questions
How much does Assessment Of Emotional Or Behavioral Problems cost?
Medicare's national average payment for Assessment Of Emotional Or Behavioral Problems (CPT 96127) is $3.30, with providers billing $21.69 on average; state rates run from $2.14 to $4.02, a meaningful but not extreme spread.
Why do providers charge more than Medicare pays?
Providers set their own chargemaster rates (billed charges), which are typically much higher than what any insurer pays. Medicare pays a fixed rate based on the procedure code and geographic location. The billed charge is relevant mainly for uninsured patients, who may face prices closer to the submitted charge.
How much does Assessment Of Emotional Or Behavioral Problems cost with insurance?
With commercial insurance, assessment of emotional or behavioral problems costs an estimated $10.00 on average (range: $7.00-$14.00), a moderate premium over Medicare's $3.30. Without insurance, the estimated cash price is $9.45.
Which state has the lowest cost for Assessment Of Emotional Or Behavioral Problems?
Puerto Rico has the lowest average Medicare payment for Assessment Of Emotional Or Behavioral Problems at $2.14, while Guam has the highest at $4.02 - a meaningful $1.87 spread.
How many providers perform Assessment Of Emotional Or Behavioral Problems?
Assessment Of Emotional Or Behavioral Problems is a widely-performed procedure: 31.6K providers billed Medicare for it in 2023 across 53 states, together handling 746.1K services for 394.5K beneficiaries.
What is the billed-to-Medicare markup for Assessment Of Emotional Or Behavioral Problems?
Providers bill 6.6x what Medicare pays for Assessment Of Emotional Or Behavioral Problems - a markup within the typical range at 557% above the Medicare rate.
Related Guides
Tips to reduce out-of-pocket costs
Your right to upfront pricing
How Medicare payments work
Decode charges and codes
Why bills exceed actual costs
Geographic pricing factors
Data from CMS Medicare Physician & Other Practitioners (2023).
Read our methodology - how this data is sourced, computed, and verified.
Related
Every figure on PlainProcedure is rendered directly from CMS Medicare Physician & Other Practitioners data, no number is typed in by an editor. This page draws directly on CMS Medicare Physician & Other Practitioners data, no figure is typed in by an editor. See our editorial standards & corrections policy, the methodology behind these numbers, or report a data error.