CPT 99214

Office Visit, Established Patient (Moderate Complexity)

CPT 99214 is the most commonly billed office visit in America, used over 100 million times per year. It covers a 30 to 39 minute visit with moderate medical decision making for an established patient. Providers charge an average of $263.55 for this visit, but Medicare pays only $135.61 for the physician fee in an office setting (1.9x markup). In a hospital setting, the physician fee drops to $84.50, but the hospital adds a separate facility fee on top.

Updated May 2026Source: CMS Physician Fee Schedule

CPT 99214 at a Glance

Average provider charge: $263.55
Medicare physician fee (office): $135.61
Medicare physician fee (hospital): $84.50 + separate facility fee
Typical markup: 1.9x over Medicare office rate

Visit duration: 30 to 39 minutes
Decision complexity: Moderate
Patient type: Established (seen before)
Beneficiaries (2023): 24.6 million

How the Medicare Rate Is Calculated

Medicare does not set prices arbitrarily. Every procedure is valued using Relative Value Units (RVUs) across three components, then multiplied by a national conversion factor of $33.4009 (2026). Here is the exact math for a 99214 visit:

Component	What It Covers	Office (Non-Facility)	Hospital (Facility)
Work RVU	Physician time, skill, and judgment	1.30	1.30
Practice Expense RVU	Rent, staff, equipment, supplies	1.83	0.80
Malpractice RVU	Professional liability insurance	0.10	0.10
Total RVU		3.23	2.20
x $33.4009	2026 conversion factor	$135.61	$84.50

Why the hospital rate is lower but you pay more: The $84.50 facility rate only covers the physician's portion. The hospital bills a separate facility fee (typically $100 to $300) on top. Combined, visits at hospital-owned practices often cost patients more than the same visit at an independent office, even though the physician payment is lower.

Medicare Rate by State

Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same 99214 visit pays differently in each state, ranging from about $98 in Arkansas to $138 in Silicon Valley (a 41% spread).

Medicare Rate by State (2026)

Medicare adjusts payments by location using Geographic Practice Cost Indices (GPCIs). Select your state to see the adjusted rate.

Sample State Rates (Office Setting)

State	Medicare Pays	Avg. Charge	Markup
Texas (Austin)	$111.14	$263.55	2.4x
California (Los Angeles)	$119.73	$263.55	2.2x
New York (Manhattan)	$122.52	$263.55	2.2x
Florida (Fort Lauderdale)	$111.38	$263.55	2.4x
Ohio	$102.59	$263.55	2.6x
Mississippi	$98.52	$263.55	2.7x
Arkansas	$97.65	$263.55	2.7x
Alaska	$132.07	$263.55	2.0x

Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $263.55 is the 2023 national average from CMS utilization data. Actual charges vary by provider.

What Insured Patients Actually Pay for a 99214 Visit

If you have health insurance, you do not pay the provider's full charge of $263.55. Your insurer has a negotiated rate with the provider, typically 120% to 200% of the Medicare rate. For a 99214 visit, that negotiated rate is usually $160 to $270. What you owe depends on your plan design:

Your Situation	What You Likely Pay	How It Works
Copay plan (deductible met or N/A)	$25 to $75	Flat copay per specialist or primary care visit
Coinsurance plan (deductible met)	$32 to $54	20% of the negotiated rate ($160 to $270)
High-deductible plan (deductible NOT met)	$160 to $270	You pay the full negotiated rate until your deductible is met
Medicare Part B	$27.12	20% of the Medicare-approved amount ($135.61)
Medicaid	$0 to $5	Minimal or no cost-sharing in most states

Key concept: the negotiated rate. Your insurer contracts with providers for a discounted rate below the sticker price. This negotiated rate is what your deductible, coinsurance, and copay are calculated against. You should never pay the full billed charge of $263.55 if you are in-network. If your Explanation of Benefits (EOB) shows the full charge applied to your balance, call your insurer.

Should You Use Insurance or Pay Cash?

If you have a high-deductible health plan (HDHP) and have not met your deductible, you are paying the full negotiated rate for every visit. For a 99214 office visit, this is typically $160 to $270 through insurance. Many providers offer a cash-pay rate of $125 to $175 for the same visit, which can be cheaper.

When Cash-Pay Wins

You are unlikely to meet your deductible this year (low expected utilization)
The provider's cash rate is below the insurer's negotiated rate
You want to see an out-of-network provider without a referral

When Using Insurance Wins

You are close to meeting your annual deductible
You expect significant medical expenses later this year
Your copay is less than the cash-pay rate
You need the visit documented for insurance continuity of care

Important trade-off: Cash payments do not count toward your insurance deductible or out-of-pocket maximum. If you pay cash for visits early in the year and then need surgery or hospitalization later, those cash payments will not have moved you closer to your deductible threshold. Factor in your overall expected healthcare spending for the year, not just the cost of this one visit.

Common Billing Problems with 99214

Upcoding from 99213 to 99214

A 99213 visit (low complexity, 20 to 29 minutes) pays $95.19, while a 99214 pays $135.61. That 42% jump creates a financial incentive to code visits at the higher level. If your visit was a brief check-in, a single straightforward issue, or lasted less than 25 minutes, ask the billing department why it was coded as 99214 rather than 99213. You can request the visit notes, which document the time spent and the complexity of decision making.

Split billing during preventive visits (modifier -25)

If you mention a new symptom during your annual physical, providers can bill the preventive visit (covered at 100% under ACA) plus a separate 99214 with modifier -25 for the "problem" portion. This is legitimate when a genuinely new medical concern is addressed. But if the conversation was brief or the issue was minor, the additional charge may not be justified. Review your EOB: if you see both a preventive code (99395-99397) and a 99214 on the same date, verify that a distinct medical issue was evaluated and documented.

Facility fee on top of the physician charge

If your doctor's office was acquired by a hospital system (increasingly common), your visit may now be billed as a hospital outpatient visit. The physician charge drops from $135.61 to $84.50, but the hospital adds a facility fee of $100 to $300, making the total higher. Check your bill for a separate "facility fee" or "outpatient hospital" line item. If this is new since your doctor joined a hospital network, this is the cause.

Time-based billing errors

Since 2021, E/M office visits can be coded based on either medical decision making or total time. If time-based, 99214 requires 30 to 39 minutes of total time (including chart review and care coordination, not just face-to-face time). If your visit was 28 minutes total, it should be coded as 99213, not 99214. Providers sometimes round up on time documentation. Your patient portal may show appointment duration that contradicts the billed code.

Related Office Visit Codes

Code	Description	Time	Medicare (Office)	Avg. Charge
99212	Established, straightforward	10-19 min	$63.29	$113.04
99213	Established, low complexity	20-29 min	$95.19	$179.97
99214	Established, moderate complexity	30-39 min	$135.61	$263.55
99215	Established, high complexity	40-54 min	$192.39	$381.33
99204	New patient, moderate complexity	45-59 min	$177.36	$395.78

Frequently Asked Questions

How much does CPT 99214 cost without insurance?

Without insurance, an office visit billed under CPT 99214 costs $150 to $350 depending on the provider and location. The national average charge is $263.55. Many providers offer a cash-pay discount of 20 to 40%, bringing the price closer to $160 to $210. For comparison, Medicare pays $135.61 for this visit in an office setting.

What is the difference between 99213 and 99214?

CPT 99213 is a 20 to 29 minute office visit requiring low complexity medical decision making. CPT 99214 is a 30 to 39 minute visit requiring moderate complexity medical decision making. The 2026 Medicare rate for 99213 is $95.19 versus $135.61 for 99214, a 42% difference. If your visit was shorter than 30 minutes or involved a straightforward issue, you may have been upcoded to 99214.

How much does insurance pay for a 99214 office visit?

Commercial insurance plans typically negotiate rates between 120% and 200% of Medicare, meaning they pay roughly $160 to $270 for a 99214 visit. Your out-of-pocket cost depends on your plan: with a copay plan you may pay $25 to $75, with coinsurance you pay 10 to 30% of the allowed amount, and if your deductible is not met you pay the full negotiated rate.

Can I be billed for 99214 during a preventive visit?

Yes. If you bring up a new medical concern during a preventive wellness visit (like an annual physical), the provider can bill a separate 99214 with modifier -25 on top of the preventive code. This is called split billing. While technically permitted, the additional charge catches many patients off guard because the preventive visit itself is covered at no cost under the ACA. Ask your provider before your visit whether raising a new concern will trigger a separate charge.

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