Office Visit (Established, Moderate-High) Cost
Office o/p est mod 30 min
$135.61Medicare 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 (established, 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 $51.11.
How CMS prices CPT 99214
Work is about 47% of the office total RVU; practice expense is about 49%. 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: $135.61. Hospital (facility) physician rate: $84.50.
Medicare patients typically owe 20% of the allowed amount after the Part B deductible — about $27 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 (Established, Moderate-High)?
This is an established-patient office visit of moderate complexity, a step above the routine check-in: managing multiple chronic conditions at once, adjusting medications with real risk, or evaluating a new problem that needs a workup. Billed by time it represents 30 to 39 minutes on the visit date. Over the last decade it has overtaken the level-three visit as the most common established-patient code in primary care, reflecting more complex visits and better documentation.
What Affects the Cost
- –It reimburses meaningfully more than 99213, and which of the two your visit becomes depends on documented complexity you cannot see from the waiting room.
- –Multi-condition patients land here repeatedly through the year, compounding the higher per-visit rate.
- –Facility fees at hospital-owned practices add a second charge to every visit at any level.
- –In-office tests, injections, or procedures stack as separate lines.
- –Specialist follow-ups at this level are priced above primary care equivalents in most charge masters.
How It Is Billed
CPT 99214 requires moderate-complexity medical decision making, for instance two or more stable chronic illnesses managed, or a new problem with uncertain prognosis, or prescription drug management, or alternatively 30 to 39 minutes of total time. The 99213-versus-99214 boundary is the most consequential coding decision in outpatient medicine and a frequent audit target in both directions. Same-day preventive plus problem billing can legitimately produce two visit codes with modifier separation.
Insurance & Coverage Notes
Cost sharing works like any office visit: flat copays hide the difference between levels on copay plans, but deductible-phase and coinsurance patients pay the real gap between a level three and level four. Medicare pays the difference too, and its 20 percent coinsurance is proportionally larger at this level. If your explanations of benefits show every single visit at level four or five, that pattern, called upcoding when unjustified, is worth a polite question to the practice.
Questions to Ask Before Booking
- 1.What determines whether my visit bills as level three or four, and what is the price difference for me?
- 2.During my deductible phase, what is the negotiated rate for this level here?
- 3.Will medication changes today push the visit to a higher level?
- 4.Are any of today's services billed separately from the visit code?
- 5.Can complex medication reviews be split across telehealth check-ins at lower cost?
Office Visit (Established, Moderate-High) (CPT 99214): questions
The 2026 national Medicare physician rate for CPT 99214 is $135.61 in an office and $84.50 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 99214 that produces an office rate of $135.61 and a hospital physician rate of $84.50 (a $51.11 gap). The hospital’s own facility charge is extra and often larger than this entire physician line.
This is an established-patient office visit of moderate complexity, a step above the routine check-in: managing multiple chronic conditions at once, adjusting medications with real risk, or evaluating a new problem that needs a workup. Billed by time it represents 30 to 39 minutes on the visit date. Over the last decade it has overtaken the level-three visit as the most common established-patient code in primary care, reflecting more complex visits and better documentation. CMS bills it as “Office o/p est mod 30 min.”
No. $135.61 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.