How much does Medicare pay for CPT 99204?

Medicare allowed an average of $157.90 per service and paid $110.99 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $409.51, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 99204?

New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more. It was billed 11,508,274 times to 11,507,036 Medicare beneficiaries by 232,660 providers in 2024.

Does 99204 pay differently in an office than a hospital?

Yes. The allowed amount averaged $160.90 in an office setting and $127.23 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 99204 most?

Nurse Practitioner, with 967,120 services from 26,997 clinicians. Next are Ophthalmology, Orthopedic Surgery, Physician Assistant.

CPT 99204

New patient office or other outpatient visit with moderate level of medical decision making, if using time, 45 minutes or more

$157.90Medicare-allowed amount per service, averaged across 11,508,274 services

Providers submitted

$409.51

Asking price, not received

Medicare allowed

$157.90

The fee schedule figure

Medicare paid

$110.99

Balance is patient coinsurance

Providers submitted an average of $409.51 for this code and Medicare allowed $157.90 — 2.6× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $110.99 (70%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $160.90
Hospital / facility: $127.23

The office rate is higher because the practice supplies the room, staff and equipment out of that payment. In a hospital the facility bills those separately, so the clinician's share is smaller — the total cost to Medicare is usually higher, not lower. 10,482,472 services were billed in an office setting and 1,025,802 in a facility.

Services: 11,508,274
Beneficiaries: 11,507,036
Providers billing it: 232,660
Total allowed: $1,817,156,465

What Medicare pays for CPT 99204

Across 11,508,274 services billed by 232,660 providers to 11,507,036 beneficiaries, Medicare allowed an average of $157.90 per service. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 99204

Specialty	Services	Beneficiaries	Avg allowed	Providers
Nurse Practitioner	967,120	967,006	$133.99	26,997
Ophthalmology	902,255	902,177	$164.61	10,152
Orthopedic Surgery	896,459	896,335	$163.26	14,539
Physician Assistant	772,768	772,686	$136.86	21,475
Cardiology	751,280	751,220	$161.47	12,858
Urology	585,833	585,771	$163.37	7,519
Otolaryngology	510,166	510,133	$162.46	6,761
Internal Medicine	485,437	485,352	$162.47	13,629
Gastroenterology	472,046	472,004	$166.10	9,041
Family Practice	423,604	423,529	$162.01	13,773
Neurology	382,574	382,549	$161.66	6,005
General Surgery	315,377	315,336	$158.56	8,435
Pulmonary Disease	301,901	301,875	$159.81	5,597
Dermatology	280,935	280,918	$164.76	6,497
Podiatry	280,019	279,987	$162.23	5,814

99204 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
California	1,201,001	$171.57	$111.74	20,105
Florida	1,158,099	$161.35	$110.86	19,557
Texas	851,684	$155.70	$111.23	17,195
New York	719,975	$177.84	$115.20	14,543
Pennsylvania	450,813	$156.61	$110.11	10,370
Illinois	430,050	$160.01	$109.71	8,883
North Carolina	379,271	$148.73	$107.95	8,478
New Jersey	374,311	$175.36	$115.17	7,390
Virginia	365,126	$155.83	$108.19	7,005
Arizona	358,352	$154.90	$109.39	6,033
Ohio	354,789	$146.35	$106.00	8,427
Georgia	334,016	$154.94	$111.06	7,462
Maryland	328,568	$167.68	$111.91	5,540
Massachusetts	290,782	$160.18	$108.19	5,980
Tennessee	284,151	$146.03	$110.38	5,655
South Carolina	272,303	$149.87	$109.81	4,648
Michigan	236,124	$153.15	$107.46	6,229
Indiana	225,846	$148.49	$109.95	4,820
Washington	218,609	$158.83	$106.99	4,734
Missouri	190,385	$147.67	$107.27	4,320
Alabama	165,599	$143.83	$110.68	3,744
Colorado	159,635	$158.93	$109.27	3,808
Oklahoma	159,512	$146.93	$109.88	2,870
Kentucky	147,135	$147.56	$109.40	3,165
Louisiana	143,977	$146.03	$108.87	3,225
Wisconsin	126,644	$143.21	$105.83	3,616
Mississippi	122,465	$142.32	$108.70	2,162
Oregon	118,062	$153.39	$106.56	2,818
Arkansas	117,198	$141.05	$109.28	2,166
Kansas	113,299	$145.05	$108.39	1,998
Minnesota	113,154	$151.81	$110.53	3,362
Nevada	105,434	$155.12	$109.06	2,053
Connecticut	103,000	$165.75	$111.08	2,741
Iowa	91,338	$142.28	$107.86	1,876
Utah	73,115	$149.71	$108.26	1,946
Nebraska	68,057	$142.87	$109.00	1,386
New Hampshire	61,784	$146.30	$100.43	1,368
Delaware	56,928	$155.43	$110.32	1,003
New Mexico	55,926	$144.86	$101.46	1,221
Idaho	51,406	$138.09	$102.83	1,198
West Virginia	46,504	$138.94	$99.92	1,176
Montana	37,196	$147.75	$102.12	818
South Dakota	34,846	$138.74	$102.56	662
District of Columbia	32,582	$175.09	$112.52	650
Maine	32,067	$141.42	$99.20	873
Hawaii	30,010	$158.97	$107.95	620
Rhode Island	29,422	$158.49	$109.07	745
North Dakota	24,551	$135.78	$99.19	551
Alaska	22,065	$192.71	$106.80	473
Wyoming	16,743	$153.17	$105.14	372
Vermont	14,511	$136.87	$95.86	329
Puerto Rico	4,132	$162.13	$113.32	177
Guam	2,549	$163.85	$106.81	44
U.S. Virgin Islands	1,735	$158.67	$97.88	40
AE	415	$154.82	$106.60	8
XX	377	$172.52	$122.94	5

Related codes

99214Established patient office or other outpatient visit$117.48
99213Established patient office or other outpatient visit$83.92
99232Subsequent hospital care$76.07
99233Subsequent hospital care$115.58
99215Established patient office or other outpatient visit$163.65
99223Initial hospital care$167.67
99285Emergency department visit$169.68
99203New patient office or other outpatient visit$104.03
99212Established patient office or other outpatient visit$52.42
99291Critical care$208.35
99222Initial hospital care$126.29
99239Hospital discharge day management$110.50

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.