Office Visit (New, Moderate-High) Cost
Office o/p new mod 45 min
$177.36Medicare physician fee2026 national office rate- ✓Your ZIP's wage-adjusted hospital and surgery centre rates
- ✓Five nearby hospitals by name, with CMS star ratings
- ✓The add-on codes that typically land on the bill
- ✓A word-for-word script for asking for a good-faith estimate
- ✓A private link you can reopen and share
- ✓Everything in the Premium report
- ✓15 nearby hospitals instead of five
- ✓Filled good-faith-estimate request letter
- ✓Bill-negotiation letter
- ✓Printable PDF download
National Medicare physician rate (2026)
Get the rate for your ZIP
CMS adjusts this CPT by locality. A five-digit ZIP is enough — no account, no insurance card.
What office visit (new, moderate-high) costs at hospitals near you
Everything above is a national average. The hospital you pick in your area moves the bill more than anything else you control.
Rates for your ZIP, 5 named hospitals with CMS ratings, the add-on codes, and the scheduler script.
One-off payment, no account and no subscription. You get a private link and an email. No medical records and no insurance card, ever.
What these numbers are
Every figure on this page is a 2026 Medicare allowed amount: the physician line comes from the Physician Fee Schedule adjusted by geographic practice-cost indices, and the facility totals come from the CMS hospital outpatient (OPPS) and ambulatory surgery centre rates. None of them is a hospital chargemaster price, your insurer's contracted rate, or a quote. Anesthesia, pathology, imaging reads and follow-up care are billed under their own codes when they apply, and an inpatient stay is paid a different way again. For this code the office and hospital physician lines differ by $60.46.
How CMS prices CPT 99204
Work is about 49% of the office total RVU; practice expense is about 47%. Localities with a high PE GPCI move this code more when practice expense is a large share.
Office vs hospital for this code
Office (non-facility) physician rate: $177.36. Hospital (facility) physician rate: $116.90.
Medicare patients typically owe 20% of the allowed amount after the Part B deductible — about $35 for the office physician fee, before any Medigap coverage. That coinsurance does not include a hospital facility fee.
Labeled private-plan and cash ranges on this page are arithmetic multiples of Medicare, not negotiated quotes. Ask the billing office for the CPT code, the site of service, and a good-faith estimate.
What Is Office Visit (New, Moderate-High)?
This is a new-patient office visit of moderate to high complexity: your first visit to a practice in three years for a problem with real depth, such as multiple symptoms needing workup, a new chronic disease like diabetes, or several interacting conditions. When billed by time it represents 45 to 59 minutes on the visit date. It is the most commonly billed new-patient level in the United States, the default for a substantive first specialist or primary care appointment.
What Affects the Cost
- –As the workhorse new-patient code, it prices well above 99203, and the level is set by the visit's complexity, not by what you expected walking in.
- –Specialist consultations commonly bill at this level, and specialist charge rates exceed primary care for the same code.
- –Diagnostic workups launched at this visit, labs, imaging referrals, and tests, are where the episode's real spending usually begins.
- –Facility fees at hospital-owned clinics inflate this visit substantially compared with independent offices.
- –Prolonged-service add-on codes can stack on top if the visit runs well past an hour.
How It Is Billed
CPT 99204 requires moderate-complexity medical decision making or 45 to 59 minutes of total time, and the new-patient three-year rule applies. It is the level most scrutinized in coding audits because it sits at the boundary where documentation must support moderate complexity: multiple problems, data reviewed, or prescription management with risk. Tests, procedures, and vaccinations during the visit always bill as additional lines.
Insurance & Coverage Notes
Standard office visit coverage applies: specialist copays are often higher than primary care copays for the identical code, and high-deductible members pay the full negotiated rate, which varies widely between health systems. Some plans require a referral for the specialist visits typically billed at this level, and skipping the referral can void coverage entirely on gatekeeper-model plans like many HMOs. The visit itself never requires prior authorization, but the tests it generates often do.
Questions to Ask Before Booking
- 1.Does my plan require a referral for this specialist before the visit is covered?
- 2.What is the negotiated or cash price for a level-four new-patient visit here?
- 3.Which tests are you likely to order, and which of those need prior authorization?
- 4.Is there a facility fee because this clinic is hospital-owned?
- 5.If the visit runs long, could additional prolonged-service charges apply?
Office Visit (New, Moderate-High) (CPT 99204): questions
The 2026 national Medicare physician rate for CPT 99204 is $177.36 in an office and $116.90 in a hospital. Enter a ZIP code to apply the geographic adjustment for your locality.
Medicare uses a different practice-expense RVU in a facility. For CPT 99204 that produces an office rate of $177.36 and a hospital physician rate of $116.90 (a $60.46 gap). The hospital’s own facility charge is extra and often larger than this entire physician line.
This is a new-patient office visit of moderate to high complexity: your first visit to a practice in three years for a problem with real depth, such as multiple symptoms needing workup, a new chronic disease like diabetes, or several interacting conditions. When billed by time it represents 45 to 59 minutes on the visit date. It is the most commonly billed new-patient level in the United States, the default for a substantive first specialist or primary care appointment. CMS bills it as “Office o/p new mod 45 min.”
No. $177.36 is the physician allowed amount. Anesthesia, facility fees, implants, imaging interpretation billed under a different code, and pathology are separate when they apply. Private-plan allowed amounts are often higher than Medicare; your deductible and coinsurance still apply.
For cash-pay surgery shopping, use this CPT as the Medicare floor when you compare written quotes. How cash-price shopping works.