Integrative GYN Membership & Out-of-Network Superbill Net-Cost Calculator

01How to use this calculator

Pick the care model that matches the clinic you are considering, then your market tier. Set the number of follow-up visits you expect in 12 months, any prolonged-time units on the intake, and whether the clinic adds preventive counseling. Choose the labs you plan to buy. Finally, enter what is left on your out-of-network deductible, your OON coinsurance and your tax bracket if you will pay with HSA or FSA dollars. Results update as you go. Use “Copy shareable link” to send your exact scenario to a partner or clinic, or print the brief to bring to your appointment.

02How the net-cost math works

The calculator runs seven steps, in this order.

1. Gross sticker cost. Visit fees for the year (or the monthly retainer × 12) plus the cash price of any labs you choose.
2. Allowed amount per code. Each CPT code’s Medicare baseline × the midpoint multiplier for your tier. 99417 is multiplied by the number of prolonged units, and 99215 by the number of follow-ups.
3. Preventive counseling. If you switch it on, 99404 is added at $260 (Tier 1), $210 (Tier 2) or $160 (Tier 3) — points inside the typical $140–$295 commercial range — on the assumption that the visit code carries modifier 25 and 99404 points to a preventive diagnosis.
4. Deductible. Total allowed minus your remaining OON deductible, never below zero.
5. Reimbursement. What is left after the deductible × your coinsurance rate. This is the estimated check from your plan.
6. Tax saving. The HSA/FSA-eligible part of what you still pay × your marginal tax bracket.
7. True net cost. Gross sticker − reimbursement − tax saving, shown per year and per month.

For example, in a Tier 2 city with one prolonged unit and four follow-ups, the modeled allowed total is about $455.86 + $62.56 + 4 × $353.24 = $1,931.37. With $1,000 of deductible left and 70% coinsurance, the estimated check is ($1,931.37 − $1,000) × 70% ≈ $651.96.

The tax bracket options are 0%, 22%, 28%, 32% and 37%. Current federal brackets include 24% rather than 28%; the 28% option can stand in for 24% federal plus a few points of state income tax. Paying through a payroll FSA can also avoid Social Security and Medicare tax, which the calculator does not count.

03Reference table: CMS baselines and market tiers

Commercial plans rarely publish out-of-network fee schedules, but most pay a multiple of Medicare. The calculator groups cities into three tiers and uses each band’s midpoint.

Table 1 · Medicare figures are approximate 2026 national non-facility values; tier multipliers and the 99404 range are IntegrativeGyn.com estimates.

Tier 1 covers NYC, San Francisco, Los Angeles, Boston and Washington DC. Tier 2 covers Chicago, Atlanta, Austin, Miami, Seattle, Denver, Dallas–Fort Worth, Houston and Phoenix. Tier 3 covers regional and suburban markets, including Nashville. See the local benchmarks on pages such as New York City or Austin, or open the calculator preset for a city: Tier 1 retainer, Tier 3 fee-for-service.

Tier 1 midpoints sit above the typical published commercial range of $260–$485 for 99205, so treat Tier 1 results as a best case. Calling your plan for its actual OON allowed amount at your clinic’s zip code is the best way to sharpen the estimate.

04Care models, labs and the retainer warning

The four care models change what you pay and how much of it a superbill can touch.

Boutique retainer

$150–$400 a month for access and visits. The retainer is never reimbursed by insurance. Whether visits under a retainer produce a payable superbill depends on how the clinic itemizes them and on your plan.

Fee-for-service cash

About $450 for the intake and $225 per follow-up. Each visit carries its own CPT code and charge, which is the cleanest case for a superbill.

Hybrid insurance + membership

A Parsley-style membership (about $150 a month) plus visits billed to insurance. The membership is non-reimbursable; visit costs follow your in-network copays and deductible.

Telehealth insurance or self-pay

Midi-style visits, often in-network, or about $250 self-pay for the intake and $150 per follow-up.

Lab options use typical clinic cash prices: DUTCH Complete about $449, GI-MAP about $459, and a comprehensive serum panel either billed to insurance or about $220 cash. Specialty tests are rarely reimbursed by insurance but are usually HSA/FSA-eligible. To build a lab plan by condition, use the lab panel cost builder.

05How to read your result

The big number is your true net cost for 12 months. The bar under it compares that with the gross sticker price, so the gap is what insurance and taxes give back. The ledger then splits the year into lines:

• Sage lines are money back: the estimated reimbursement check and the HSA/FSA tax saving.
• Ochre lines show how much of the allowed amount your deductible absorbs. A large ochre line means most of this year’s visits go toward your deductible, which still counts toward future claims in the same plan year.
• Clay lines are costs no plan will cover: retainer access fees and products.

If the reimbursement line is near $0, check two inputs first: the deductible remaining and the care model. A high deductible early in the year, or a retainer model with few itemized visits, is the usual reason. If the net cost looks too good, check the tier; a Tier 1 setting on a plan that actually pays 140% of Medicare will overstate your check.

Bring the printed brief to the clinic and ask three questions: which CPT codes they bill for each visit, whether they add modifier 25 when billing 99404, and whether the superbill includes NPI, tax ID and place of service. The superbill and HSA/FSA guide covers each item.

06Limitations

This is an estimate, not a benefits quote. Its main limits:

• Your plan’s multiplier is unknown. Plans may pay less than the tier midpoint, use FAIR Health percentiles, or apply a fixed maximum allowable.
• The lesser-of rule. Plans generally allow the lower of their allowed amount and the clinic’s billed charge. The calculator applies this rule using typical clinic charges ($450 intake, $225 follow-up, $95 per prolonged unit, $195 counseling); if your clinic charges less, your real check will be smaller.
• No OON benefits, no check. HMO and EPO plans usually pay nothing on superbills.
• Coding and documentation. Time thresholds, prolonged units and same-day 99404 depend on what the clinician documents; plans may reduce or deny lines.
• Hormone pellets are excluded. Pellet insertion is usually denied for women; compare modalities in the BHRT cost comparator.
• Tax treatment varies. HSA/FSA eligibility of membership fees is not settled for every arrangement; confirm with your administrator or tax adviser.

Prices and allowables change; confirm current figures with your clinic and plan. This calculator is educational and is not individual medical, insurance or tax advice.