How much does Medicare pay for CPT 99426?

Medicare allowed an average of $60.08 per service and paid $46.71 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $140.54, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

Does 99426 pay differently in an office than a hospital?

Yes. The allowed amount averaged $60.34 in an office setting and $44.27 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 99426 most?

Urology, with 124,043 services from 560 clinicians. Next are Ophthalmology, Cardiology, Nurse Practitioner.

CPT 99426

Principal care management services for a single high-risk disease, first 30 minutes of clinical staff time directed by health care professional, per calendar month

$60.08Medicare-allowed amount per service, averaged across 453,609 services

Providers submitted

$140.54

Asking price, not received

Medicare allowed

$60.08

The fee schedule figure

Medicare paid

$46.71

Balance is patient coinsurance

Providers submitted an average of $140.54 for this code and Medicare allowed $60.08 — 2.3× 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 $46.71 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $60.34
Hospital / facility: $44.27

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. 446,277 services were billed in an office setting and 7,332 in a facility.

Services: 453,609
Beneficiaries: 115,710
Providers billing it: 1,927
Total allowed: $27,252,829

What Medicare pays for CPT 99426

Across 453,609 services billed by 1,927 providers to 115,710 beneficiaries, Medicare allowed an average of $60.08 per service. That is 3.9 services per beneficiary, so this is a code patients typically receive more than once. 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 99426

Specialty	Services	Beneficiaries	Avg allowed	Providers
Urology	124,043	22,949	$60.81	560
Ophthalmology	52,551	14,919	$63.96	216
Cardiology	47,381	10,108	$61.55	122
Nurse Practitioner	44,438	12,971	$50.68	168
Physician Assistant	25,132	8,252	$52.96	83
Internal Medicine	23,023	7,630	$60.72	59
Rheumatology	14,385	3,640	$65.03	55
Pulmonary Disease	13,232	2,895	$60.02	26
Nephrology	12,867	2,635	$59.75	92
Hematology-Oncology	10,432	2,890	$63.20	107
Emergency Medicine	9,899	2,696	$64.80	7
Physical Medicine and Rehabilitation	8,998	2,183	$62.13	17
Interventional Cardiology	8,310	1,379	$59.65	41
Neurology	7,569	2,460	$60.82	33
Orthopedic Surgery	6,714	5,090	$60.38	102

99426 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
Texas	54,677	$59.19	$46.63	182
New York	43,041	$62.01	$45.90	148
Florida	40,857	$60.97	$46.50	106
Maryland	37,061	$64.74	$46.36	141
Arizona	26,786	$58.73	$45.72	102
Tennessee	22,127	$57.43	$45.05	77
California	18,887	$61.71	$45.31	96
Colorado	16,402	$63.61	$46.39	61
Virginia	16,400	$61.57	$46.64	83
Ohio	14,385	$58.57	$45.67	73
Indiana	11,301	$57.36	$46.87	83
New Jersey	10,995	$66.95	$47.30	69
Arkansas	10,963	$53.52	$45.80	27
Illinois	10,197	$58.25	$44.80	65
Louisiana	9,807	$58.32	$45.67	40
Kentucky	9,744	$59.04	$47.12	19
Missouri	9,049	$51.85	$41.41	53
Delaware	7,217	$60.92	$45.14	22
Massachusetts	6,749	$60.26	$43.05	25
Georgia	6,686	$56.47	$44.91	38
Washington	5,698	$65.97	$48.07	25
South Carolina	5,614	$60.24	$46.14	33
Alabama	5,502	$56.05	$46.76	36
Iowa	5,412	$54.59	$42.60	12
Pennsylvania	5,279	$57.73	$44.27	42
Nevada	4,767	$61.30	$47.82	24
Oklahoma	4,356	$56.34	$45.97	10
Mississippi	4,266	$58.16	$45.80	14
Connecticut	3,661	$64.78	$46.19	10
North Carolina	3,635	$58.46	$46.27	32
Michigan	3,127	$56.30	$43.41	46
Idaho	2,897	$54.88	$44.08	20
Utah	2,144	$61.92	$46.59	3
Minnesota	2,018	$59.39	$44.61	19
Oregon	1,912	$63.27	$45.26	17
New Mexico	1,729	$57.45	$47.00	7
District of Columbia	1,548	$59.73	$42.29	5
Rhode Island	1,282	$51.45	$41.21	2
Puerto Rico	1,157	$63.09	$47.78	2
Kansas	849	$56.15	$43.55	12
Nebraska	745	$56.76	$47.88	13
West Virginia	728	$53.41	$40.76	7
Hawaii	469	$65.24	$47.17	5
Montana	460	$61.86	$39.51	6
Wyoming	276	$59.91	$45.17	1
Wisconsin	259	$56.35	$45.58	7
North Dakota	245	$62.11	$47.20	3
Maine	142	$47.67	$41.26	1
Alaska	39	$77.90	$48.53	1
New Hampshire	34	$62.42	$48.54	1
South Dakota	28	$50.36	$40.98	1

Related codes

99490Chronic care management services$59.70
99439Chronic care management services for two or more chronic conditions$46.13
99497Advance care planning$73.95
99457Management using the results of remote vital sign monitoring per calen$48.61
99458Management using the results of remote vital sign monitoring per calen$39.11
99454Remote monitoring of physiologic parameters$47.97
99489Complex chronic care management services for two or more chronic condi$67.00
99442Telephone medical discussion$83.84
99443Telephone medical discussion$120.39
99487Complex chronic care management services for two or more chronic condi$124.70
99496Transitional care management services for problem of high complexity$252.87
99484Care management services for behavioral health conditions$50.05

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.