How Much Does New Patient Office Visit - Moderate Complexity Cost?
Also known as: Office o/p new mod 45 min (CPT 99204)
A comprehensive first-time visit for a problem that requires thorough evaluation and possibly multiple treatment options.
New Patient Office Visit - Moderate Complexity (CPT 99204) costs $117 at Medicare rates.
The rates shown below represent the complete Medicare reimbursement for this service. No separate facility fee applies for this type of procedure.
Patient Guide: New Patient Office Visit - Moderate Complexity
What you need to know before your appointment
What to Expect
Expect a detailed health history review, thorough physical exam, and discussion of test results or treatment plans. The doctor may order labs or imaging.
How Long Does It Take?
30-45 minutes
Common Reasons Doctors Order This
Chronic pain evaluation, new diagnosis workup, multiple health concerns, pre-surgical consultation
How to Prepare
Bring all medical records, test results, and imaging from other providers. Prepare a list of questions.
Procedures Commonly Done Together
These procedures are frequently performed alongside Office o/p new mod 45 min
What Insurance Companies Actually Pay
Real negotiated rates from 7 hospitals across 5 states (from hospital price transparency filings)
| Insurance Company | Avg Rate | Range | Hospitals |
|---|---|---|---|
| Aetna | $357 | $43 - $620 | 5 |
| BCBS-TX | $314 | $192 - $417 | 2 |
| United | $138 | $30 - $320 | 3 |
| Cigna | $173 | $92 - $477 | 4 |
| CHC | $236 | $45 - $375 | 2 |
| Kaiser | $38 | $29 - $51 | 1 |
| Multiplan | $228 | $100 - $395 | 2 |
| Humana | $293 | $101 - $443 | 2 |
| Peach State | $258 | $115 - $497 | 2 |
| BCBS - Anthem | $258 | $105 - $356 | 1 |
| OPTUM | $331 | $184 - $563 | 1 |
| Employers Health Network | $95 | $95 | 2 |
How to Reduce Your Cost for Office o/p new mod 45 min
Practical tips that can save you hundreds or thousands of dollars
- 1 Ask about cash-pay discounts
Many hospitals and clinics offer 20-40% discounts for self-pay patients. Always ask before scheduling.
- 2 Compare facility vs. office setting costs
For this procedure, the office rate ($177) differs from the facility rate ($117). Ask if it can be done in an office setting.
- 3 Shop around — costs vary significantly
Costs can vary 2-3x between providers in the same city. Get quotes from multiple facilities.
How is the Price Calculated?
Medicare calculates procedure payments using Relative Value Units (RVUs). Each procedure has three components multiplied by a conversion factor ($33.40 in 2026) and adjusted by geographic cost indices.
Payment = Total RVU (5.31) x CF ($33.40) = $177
Related Procedures
Similar procedures in the same category or body system
Consider These Alternatives
Depending on your clinical situation, these alternatives may be appropriate and could save you money.
Note: Alternative procedures may not be clinically appropriate for all patients. Always consult your physician to determine the best option for your specific situation.
Frequently Asked Questions
How much does Office o/p new mod 45 min cost?
The Medicare facility rate for Office o/p new mod 45 min is $117. Commercial insurance rates typically range from 150% to 250% of Medicare (varies by plan).
How much does Office o/p new mod 45 min cost without insurance?
Without insurance, the cost of Office o/p new mod 45 min can range from 150% of Medicare to 500% of Medicare depending on the facility. Many hospitals and clinics offer self-pay discounts of 20-40% off their chargemaster price. Always ask about cash pricing before your visit.
Does insurance cover Office o/p new mod 45 min?
Most commercial health insurance plans and Medicare cover Office o/p new mod 45 min when ordered by a physician for a medically necessary reason. Your out-of-pocket cost depends on your plan's deductible, copay/coinsurance structure, and whether you use an in-network provider. Check with your insurance company before scheduling to confirm coverage and get a cost estimate.
Why does the cost vary so much by location?
Medicare adjusts payments using Geographic Practice Cost Indices (GPCIs) that reflect local differences in physician work costs, practice expenses, and malpractice insurance. Manhattan, San Francisco, and other high-cost areas pay significantly more than rural regions. Commercial insurers follow similar geographic patterns.