How much does Medicare pay for CPT 99459?

Medicare allowed an average of $22.03 per service and paid $16.63 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $64.58, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 99459?

Pelvic exam. It was billed 233,304 times to 193,870 Medicare beneficiaries by 4,132 providers in 2024.

Does 99459 pay differently in an office than a hospital?

Yes. The allowed amount averaged $22.06 in an office setting and $20.99 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 99459 most?

Obstetrics & Gynecology, with 140,469 services from 2,533 clinicians. Next are Nurse Practitioner, Urology, Gynecological Oncology.

CPT 99459

Pelvic exam

$22.03Medicare-allowed amount per service, averaged across 233,304 services

Providers submitted

$64.58

Asking price, not received

Medicare allowed

$22.03

The fee schedule figure

Medicare paid

$16.63

Balance is patient coinsurance

Providers submitted an average of $64.58 for this code and Medicare allowed $22.03 — 2.9× 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 $16.63 (75%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $22.06
Hospital / facility: $20.99

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. 227,379 services were billed in an office setting and 5,925 in a facility.

Services: 233,304
Beneficiaries: 193,870
Providers billing it: 4,132
Total allowed: $5,139,687

What Medicare pays for CPT 99459

Across 233,304 services billed by 4,132 providers to 193,870 beneficiaries, Medicare allowed an average of $22.03 per service. That is 1.2 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 99459

Specialty	Services	Beneficiaries	Avg allowed	Providers
Obstetrics & Gynecology	140,469	117,910	$22.78	2,533
Nurse Practitioner	29,886	24,068	$18.70	633
Urology	24,597	21,539	$22.88	392
Gynecological Oncology	20,561	15,826	$22.83	242
Physician Assistant	14,279	11,729	$18.90	263
Certified Nurse Midwife	558	493	$23.43	22
Internal Medicine	533	425	$22.31	10
Osteopathic Manipulative Medicine	525	311	$24.20	2
Certified Clinical Nurse Specialist	422	327	$16.92	2
Family Practice	393	351	$23.89	14
Surgical Oncology	351	231	$22.51	2
Endocrinology	154	145	$26.52	1
General Surgery	142	138	$23.95	2
General Practice	114	97	$20.48	3
Undefined Physician type	105	104	$24.35	4

99459 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
Florida	27,482	$20.94	$16.33	378
New York	22,916	$25.56	$16.72	380
California	16,994	$26.01	$16.86	228
Texas	14,215	$21.09	$16.43	264
Virginia	13,801	$22.07	$16.54	202
Maryland	13,304	$23.54	$15.96	215
Pennsylvania	12,515	$21.18	$15.94	253
New Jersey	10,950	$24.82	$16.14	204
North Carolina	9,078	$20.01	$16.23	190
Illinois	8,402	$21.38	$16.39	147
Georgia	7,002	$20.21	$16.63	130
Tennessee	6,934	$19.58	$16.30	108
Arizona	4,495	$20.50	$16.20	62
Ohio	4,409	$19.88	$16.25	94
Massachusetts	4,394	$25.15	$16.72	53
Michigan	4,385	$20.92	$16.51	115
Alabama	4,075	$19.10	$16.62	88
Oklahoma	3,879	$18.96	$16.13	60
South Carolina	3,807	$19.74	$16.40	60
Indiana	3,209	$19.96	$15.77	70
Mississippi	3,187	$18.77	$16.33	59
Oregon	2,940	$21.56	$15.41	66
Kansas	2,557	$19.70	$15.75	38
Missouri	2,513	$18.92	$15.62	59
Colorado	2,104	$22.84	$16.30	61
Kentucky	1,980	$18.37	$15.43	48
Washington	1,965	$22.74	$15.66	63
Minnesota	1,880	$21.36	$15.78	55
Delaware	1,790	$21.14	$14.74	19
Connecticut	1,751	$23.79	$16.80	36
Nebraska	1,716	$20.03	$16.03	22
Nevada	1,357	$21.63	$16.74	40
Arkansas	1,344	$18.43	$16.19	37
Louisiana	1,333	$19.00	$16.22	33
Maine	1,296	$21.70	$16.24	19
Rhode Island	925	$23.16	$16.86	22
Utah	787	$19.96	$16.30	23
Wisconsin	778	$20.56	$15.88	21
District of Columbia	777	$25.62	$16.69	20
New Hampshire	704	$21.38	$15.26	8
Idaho	593	$19.70	$15.42	13
Montana	540	$21.38	$16.24	11
Hawaii	520	$25.23	$17.41	9
Iowa	430	$19.49	$16.24	16
North Dakota	323	$21.53	$15.99	9
West Virginia	320	$19.70	$17.50	5
New Mexico	299	$19.60	$15.62	7
South Dakota	192	$21.92	$15.60	3
Wyoming	127	$21.05	$15.49	7
Puerto Rico	19	$22.33	$16.73	1
U.S. Virgin Islands	11	$17.46	$14.18	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
99426Principal care management services for a single high-risk disease$60.08

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.