What Insurers Pay for New Patient Visit, 45m (CPT 99204): 2026 Benchmarks

Part of our payer reimbursement benchmarks series — 16 payers cover 99204, with a national median of $181 and a 2.2× spread between the highest- and lowest-paying payers.

Official CMS descriptor: Office o/p new mod 45 min

MRF vintage2026-Q2

Rates analyzed784

Generated2026-06-12

Billing classProfessional

National benchmarks

Physician fee · national median$181all payers

IQR$180–$18325th–75th pct

Payer Spread2.2×top ÷ bottom payer

State Spread1.3×top ÷ bottom state

% of Medicare125%commercial median

What this number is — and isn’t

This is the physician fee— what the insurer has contracted to pay a clinician or medical group for this service, as published in the insurer’s Transparency in Coverage filing. It does not include any facility fee if the service happens in a hospital or outpatient center (that generates a separate institutional claim). This number is not a patient cost estimate; what you owe depends on your deductible and coinsurance.

By payer

Negotiated medians by payer

Payer-level negotiated medians for CPT 99204
Payer	Median rate	States covered
Anthem (Elevance)	$240–$250	53
Blue Cross Blue Shield (HCSC)	$200–$210	12
Blue Cross Blue Shield of North Carolina	$200–$210	54
10 more payers between these — medians by payer and state Unlock with Pro →
Blue Cross Blue Shield of Kansas	$140–$150	13
Blue Cross Blue Shield of Arkansas	$100–$110	53
Blue Cross Blue Shield FEP	$100–$110	53

Anthem (Elevance) pays a median of $240–$250 for 99204 — 2.2× more than Blue Cross Blue Shield FEP at $100–$110. Caveat: percent-of-charge and per-diem contract artifacts can inflate or deflate MRF-derived medians; see methodology.

Payer-level medians are aggregated across all states each payer covers. Filter to your payer and state →

Rates by state

State-level negotiated medians for CPT 99204
State	Median	Coverage
CO	$185	Full
CT	$185	Full
NY	$185	Full
PA	$185	Full
CA	$185	Full
All 56 states and territories, including yours Unlock with Pro →

Showing the 5 highest-median states. State medians are computed from payer-level medians; cells with fewer than 5 underlying rates are suppressed.

Methodology

The national median for 99204 is computed using a median-of-state-medians method: within each state we compute the median of all payer-reported in-network rates, then take the median of those state medians. This prevents high-volume states from dominating the national figure.

Cells with fewer than 5 underlying rates are suppressed before aggregation to prevent thin markets from distorting state or national summaries. A professional billing class means rates reflect the clinician fee schedule — what an individual physician or group practice bills. The two billing classes are not directly comparable for the same procedure code.

All rates are derived from federally-mandated Transparency in Coverage Machine-Readable Files (45 CFR Part 147). We do not model, estimate, or invent prices — every figure traces back to a payer-published filing. A median is a summary, not a quote. No individual provider necessarily charges the median; percentile ranges exist precisely because prices vary. Verify specifics with your payer or provider. See our full methodology.

Payers contract under different structures (fee schedule, percent of billed charges, case rates); medians that diverge sharply from the national range usually reflect a different payment methodology rather than a genuinely different price.

Cite this data

CareCost Explorer, “Negotiated rate benchmarks for CPT 99204,” 2026-Q2 Transparency in Coverage data, carecostexplorer.com/benchmarks/procedure/99204. Generated 2026-06-12.

Journalists and researchers: this data is free to cite with attribution.

Frequently Asked Questions

What is the average negotiated rate for CPT 99204?

The national median negotiated rate for CPT 99204 (Office o/p new mod 45 min) is $181, computed from 784 rates across 16 payers and 56 states and territories. Individual payer medians range from $100–$110 (Blue Cross Blue Shield FEP) to $240–$250 (Anthem (Elevance)). A median is a summary — your actual contracted rate depends on your specific payer and state.

Why do rates for CPT 99204 vary 2.2× between payers?

Negotiated rates are set individually between each payer and each provider network, so payer-level medians reflect different provider mixes, contract vintages, and market leverage. For CPT 99204, the top payer median ($240–$250, Anthem (Elevance)) is 2.2× the bottom payer median ($100–$110, Blue Cross Blue Shield FEP). Percent-of-charge and per-diem contract structures can also inflate or deflate MRF-derived figures; see our methodology for details.

What percent of Medicare do commercial payers pay for CPT 99204?

Commercial payers pay a median of 125% of the Medicare allowed amount for CPT 99204. The Medicare average allowed amount is $145; the commercial median is $181. This ratio varies by payer and region — some payers set rates as a direct percentage of Medicare, while others use independent fee schedules.

How do I find my payer's rate for CPT 99204 in my state?

CareCost Explorer lets you filter by payer and state to see the specific negotiated median for your market. The data above shows payer-level medians aggregated across all states each payer covers; your state-specific rate may differ. Use the full Explorer tool at carecostexplorer.com/pricing to query your payer and geography directly.

Anthem (Elevance) pays a median of $240–$250 for 99204 nationally. See the rate for your state →

See the rate for your payer, in your market.

Anthem (Elevance)'s median for 99204 is $240–$250 — but your state and plan tell a different story. 36M+ rates, queryable.

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