Office Visit (New, High) Cost
Office o/p new hi 60 min
$236.81Medicare 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, 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 $76.49.
How CMS prices CPT 99205
Work is about 49% of the office total RVU; practice expense is about 46%. 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: $236.81. Hospital (facility) physician rate: $160.32.
Medicare patients typically owe 20% of the allowed amount after the Part B deductible — about $47 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, High)?
This is the highest-level new-patient office visit, reserved for genuinely complex first encounters: multiple serious conditions, a diagnosis that could threaten life or function, or decisions about major interventions. Billed by time, it means 60 to 74 minutes with the clinician on the visit date. Typical examples include a first oncology consultation, a complicated multi-system workup, or a new patient with several unstable chronic diseases.
What Affects the Cost
- –It is the most expensive standard office visit code, and practices reserve it for their longest, most involved new consultations.
- –The specialists who bill it most, oncologists, rheumatologists, complex-care internists, tend to practice in hospital systems where facility fees compound the professional charge.
- –Visits this complex almost always launch expensive diagnostics: advanced imaging, biopsies, or specialty labs, each billed separately.
- –Prolonged-service add-on codes attach beyond 74 minutes, extending the charge further.
- –Second-opinion consultations at academic centers often bill at this level with academic-center pricing.
How It Is Billed
CPT 99205 demands high-complexity medical decision making or 60 to 74 minutes of documented time, and payers audit it precisely because it pays the most; the medical record must reflect the severity and data involved. The three-year new-patient rule applies. Everything beyond the conversation and exam, tests, procedures, infusions, bills separately, and time beyond 74 minutes adds the prolonged-services code in 15-minute increments.
Insurance & Coverage Notes
Coverage terms mirror any specialist office visit: referral requirements on gatekeeper plans, specialist-tier copays, or full negotiated rates against a deductible. Because this level often marks the start of major treatment episodes, the more consequential insurance work is downstream: confirming the recommended tests, procedures, and drugs are in network and authorized. For second opinions, many plans cover them fully, and some cancer policies actively encourage them; verify whether the academic center you choose is in network first.
Questions to Ask Before Booking
- 1.What is the charge for this highest-level consultation, including any facility fee?
- 2.Does my plan need a referral on file before this visit?
- 3.Which of the tests and treatments you are recommending need prior authorization?
- 4.Is every provider involved in my workup, radiology, pathology, labs, in my network?
- 5.If this is a second opinion, does my plan have a program that covers it in full?
Office Visit (New, High) (CPT 99205): questions
The 2026 national Medicare physician rate for CPT 99205 is $236.81 in an office and $160.32 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 99205 that produces an office rate of $236.81 and a hospital physician rate of $160.32 (a $76.49 gap). The hospital’s own facility charge is extra and often larger than this entire physician line.
This is the highest-level new-patient office visit, reserved for genuinely complex first encounters: multiple serious conditions, a diagnosis that could threaten life or function, or decisions about major interventions. Billed by time, it means 60 to 74 minutes with the clinician on the visit date. Typical examples include a first oncology consultation, a complicated multi-system workup, or a new patient with several unstable chronic diseases. CMS bills it as “Office o/p new hi 60 min.”
No. $236.81 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.