CPT 99204 cost and Medicare rate
For code 99204, new patient office or other outpatient visit with moderate level of medical decision making, Medicare's 2026 rate in an office or clinic nationally is about $177. In 2024, providers nationally typically billed about $411. Medicare rates are a common benchmark, not what every plan pays.
What CPT 99204 is
New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more.
Office is the rate when the service is done in a clinic, office or imaging center, and covers the whole service. Facility is the doctor's part when it is done in a hospital or surgery center, which bills its own facility fee separately. The hospital outpatient rate is Medicare's rate for that facility fee.
What Medicare pays for 99204 nationally
| Setting | Medicare 2026 | Medicare allowed 2024 | Typically billed 2024 |
|---|---|---|---|
| Office or clinic | $177.36 | $160.28 | $410.82 |
| Hospital or surgery center (doctor's part) | $116.90 | $127.13 | $386.91 |
Medicare 2026 is the national fee schedule rate (conversion factor 33.4009). "Medicare allowed" and "typically billed" are averages from Medicare claims in 2024.
If the visit was in a hospital or a hospital-owned clinic
For code 99204, new patient office or other outpatient visit with moderate level of medical decision making, Medicare's 2026 rate for the doctor's part in a hospital nationally is about $117. In 2024, providers nationally typically billed about $387. Hospitals also bill their own facility fee on top of this, and Medicare rates are a common benchmark, not what every plan pays.
A hospital-owned clinic usually adds its own facility fee as code G0463, which Medicare pays at about $136 nationally.
Medicare's national hospital outpatient (OPPS) rate for the hospital's own facility fee, before each hospital's local wage adjustment, which raises it in high-cost areas and lowers it in low-cost ones. The doctor bills separately under the fee schedule.
See HCPCS G0463, the hospital clinic facility fee, and why a hospital visit has two bills.
99204 by state
Where you were treated changes the benchmark. Medicare's 2026 rate depends on the pricing area. The table shows the rest-of-state rate and the range across each state's pricing areas; some big cities have their own, higher rate. Billed amounts are what providers typically billed in an office or clinic in 2024.
| State and Medicare pricing area | Office 2026 | Hospital, doctor's part 2026 | Office range in state | Typically billed 2024 |
|---|---|---|---|---|
| California Rest of California | $183.04 | $116.78 | $183.04 to $219.66 29 pricing areas | $462.76 |
| New York Rest of New York | $170.85 | $113.42 | $170.85 to $205.38 5 pricing areas | $591.73 |
| Texas Rest of Texas | $172.37 | $115.00 | $169.36 to $181.40 8 pricing areas | $390.53 |
| Florida Rest of Florida | $177.76 | $119.97 | $177.76 to $193.00 3 pricing areas | $417.88 |
| Illinois Rest of Illinois | $174.69 | $119.50 | $174.69 to $188.76 4 pricing areas | $391.33 |
| Ohio Statewide | $170.25 | $115.05 | One rate statewide | $374.76 |
| Georgia Rest of Georgia | $169.99 | $116.06 | $169.99 to $180.55 2 pricing areas | $433.23 |
| Washington Rest of Washington | $180.94 | $117.28 | $180.94 to $198.96 2 pricing areas | $423.35 |
| Pennsylvania Rest of Pennsylvania | $170.15 | $114.65 | $170.15 to $183.85 2 pricing areas | $364.71 |
| Arizona Statewide | $173.65 | $115.07 | One rate statewide | $387.36 |
What your charge for 99204 means
Med Bill Check compares a charge with Medicare's rate and with what providers typically billed. Here is how it reads three national charges:
- Charged $180: Your $180 is close to the Medicare rate, which is a good sign. Medicare rates are a common benchmark, not what every plan pays.
- Charged $350: Your $350 is about 2 times the Medicare rate, though below what providers typically billed. Medicare rates are a common benchmark, not what every plan pays.
- Charged $710: Your $710 is about 4 times the Medicare rate and 1.7 times what providers typically billed. That is a common benchmark rather than a verdict, and asking for an itemized bill or a self-pay discount is a sensible next step.
Medicare rates are a common benchmark, not what every plan or provider charges, and never proof a bill is wrong. Enter your own charge and state on the home page for your figures.
Common billing questions for 99204
- Units: Medicare's automated limit for 99204 is 1 unit for one patient on one day (NCCI Medically Unlikely Edits). If your bill shows more, ask them to confirm the units. Medicare limits (MUE) are the most units Medicare pays automatically for one patient on one day. Going over is a reason to ask, not proof of an error, since some cases are allowed with records.
- Duplicates and services you did not get: Look for duplicate lines, services you did not receive, and unit counts that look high.
How to question a charge for 99204
- Ask for an itemized bill with codes, units and prices. Itemized bill letter.
- Compare each line with your Explanation of Benefits if you have insurance.
- Ask the billing office to review the charge in writing, and to hold the account from collections meanwhile. Charge review letter.
- Ask for a prompt-pay or self-pay discount, or an interest-free payment plan. Discount letter.
- If it was a hospital, ask for its financial assistance policy. Financial assistance letter and which hospitals must offer it.
With your code and amount, the review letter adds the benchmark for you, for example: For reference, Medicare's 2026 fee schedule rate for code 99204 nationally is about $177, and Medicare's published data shows providers nationally typically billed about $411 in 2024.
Keep a copy of everything you send, and note the date and the name of anyone you speak to. If you have insurance, call your insurer too. They can check whether the claim was processed correctly.
Quick answers
- What is CPT 99204?
- New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more.
- How much does Medicare pay for 99204 in 2026?
- Nationally, Medicare's 2026 rate is $177.36 in an office or clinic and $116.90 for the doctor's part in a hospital or surgery center.
- What do providers typically charge for 99204?
- In 2024, providers nationally typically billed $410.82 for 99204 in an office or clinic.
- Is $710 for 99204 too much?
- Your $710 is about 4 times the Medicare rate and 1.7 times what providers typically billed. That is a common benchmark rather than a verdict, and asking for an itemized bill or a self-pay discount is a sensible next step.
- How much is 99204 in Texas?
- For code 99204, new patient office or other outpatient visit with moderate level of medical decision making, Medicare's 2026 rate in an office or clinic in Texas is about $172. In 2024, providers in Texas typically billed about $391. Medicare rates are a common benchmark, not what every plan pays.
- How many units of 99204 can be billed in one day?
- Medicare's automated limit is 1 for one patient on one day. Going over is a reason to ask, not proof of an error, since some cases are allowed with records.
Sources
- CMS Medicare Physician Fee Schedule, 2026 (pfs.data.cms.gov)
- CMS Medicare Physician and Other Practitioners by Geography and Service, 2024 data (data.cms.gov)
- CMS NCCI Medically Unlikely Edits, effective 2026-10-01
General information, not medical, legal or financial advice. Medicare rates are a common benchmark, not what every plan or provider charges. For your own bill, check with the billing office, your insurer or your doctor.
Ask Med Bill Check yourself
Enter the code or the service in plain words, your state and what you were charged, and see how it compares with Medicare's rate. Open Med Bill Check, free, no sign-up.
In Claude or any app that takes MCP connectors, add https://goodturn-mcp.pages.dev/medbillcheck/mcp and ask: “Is $350 for 99204 in Texas too much?”
More doctor's office visits
- CPT 99202: New patient office or other outpatient visit with straightforward…
- CPT 99203: New patient office or other outpatient visit with low level of…
- CPT 99205: New patient office or other outpatient visit with a high level of…
- CPT 99211: Office or other outpatient visit for the evaluation and management…
- CPT 99212: Established patient office or other outpatient visit with…
- CPT 99213: Established patient office or other outpatient visit with low level…
- CPT 99214: Established patient office or other outpatient visit with moderate…
- CPT 99215: Established patient office or other outpatient visit with high level…