Insurance Fee Schedule
Estimated UCR-Based Rates
2265 W. Fair Ave. | Lancaster, OH 43130
Phone: (740) 494-1470 | Fax: (740) 494-1472
www.peakperformss.com
⚖️ Legal & Industry Disclaimer
The fees listed below represent the typical charges billed for insured services at Peak Performance Sport & Spine. These charges are based on regional Usual, Customary, and Reasonable (UCR) rates, as published by PMIC (Practice Management Information Corporation), an industry-recognized authority on healthcare pricing standards.
Please note: For patients with commercial or major medical insurance, actual out-of-pocket costs may be significantly reduced due to contractual agreements with our in-network insurance partners. These agreements result in a contracted rate and a corresponding write-off from the standard fee schedule, as required by law and payer guidelines.

Office Visit
Type |
New Code |
Est. Code |
Charge |
Expanded Exam |
99202 |
99212 |
$140 / $100 |
Detailed Exam |
99203 |
99213 |
$225 / $160 |
Comprehensive Exam |
99204 |
99214 |
$340 / $230 |
Chiropractic Manipulation
Description |
Code |
Charge |
Manipulation 1-2 Regions |
98940 |
$50 |
Manipulation 3-4 Regions |
98941 |
$60 |
Extraspinal 1 or More Regions |
98943 |
$45 |
Modalities
Description |
Code |
Charge |
Traction Mechanical |
97012 |
$30 |
E-Stim (Unattended) |
97014 |
$35 |
E-Stim (Unattended) |
G0283 |
$35 |
Infrared Therapy |
97026 |
$25 |
Ultrasound |
97035 |
$35 |
Shockwave (ESWT) |
0101T |
$99 |
Vasopneumatic Therapy |
97016 |
$40 |
Therapeutic Procedures
Description |
Code |
Charge |
Therapeutic Exercises, per 15min |
97110 |
$65 |
Neuromuscular Re-Ed, per 15min |
97112 |
$70 |
Massage, per 15min |
97124 |
$40 |
Manual Therapy/Myofascial, per 15min |
97140 |
$65 |
Other
Description |
Code |
Charge |
Kinesiology Tape, per region |
99070 |
$15 |
X-rays
Description |
Code |
Charge |
Complete Spine A/P & Lateral |
72082 |
$190 |
Cervical 3 Views or Less |
72040 |
$100 |
Cervical 4-5 Views |
72050 |
$185 |
Cervical 6+ Views |
72052 |
$195 |
Thoracic 2 Views |
72070 |
$100 |
Lumbosacral 2-3 Views |
72100 |
$120 |
Lumbosacral Minimum 4 Views |
72110 |
$170 |
Lumbosacral Comp. Views Incl Bending |
72114 |
$220 |
Shoulder 1 View |
73020 |
$70 |
Shoulder 2 Views |
73030 |
$110 |
Hand 2 Views |
73120 |
$80 |
Hip Unilateral 1 View |
73501 |
$85 |
Hip Unilateral Comp 2 Views |
73502 |
$120 |
Hip Bilateral Min 2 Views Each Hip |
73521 |
$130 |
Knee 1-2 Views |
73560 |
$95 |
Foot 2 Views |
73620 |
$65 |
Wrist 2 Views |
73100 |
$95 |
Ankle 2 Views |
73600 |
$90 |
DME (Durable Medical Equipment)
Description |
Code |
Charge |
TENS Unit |
E0730 |
$300 |
Posture Pump |
E0849 |
$300 |
LSO Brace |
L0648 |
$700 |
LSO Brace w/ Side Panels |
L0650 |
$800 |
Knee Brace |
L1845 |
$1200 |
Knee Brace Suspension Sleeve |
L2397 |
$130 |
Foot Orthotics |
L3020 |
$250 |