CPT 49204 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address high-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Digestive System |
| Common Place of Service | • 21 - Inpatient Hospital • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • 80 - Assistant surgeon • 22 - Increased Procedural Services |
| Complexity Level | High |
| Medicare Fee Schedule | View Medicare rates for 49204 |
National average reimbursement for CPT 49204 by major payers:
$1,852.81
$1,779.67
$1,654.58
$2,316.72
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
Select a payer to view fee schedule data Choose a payer from the options above to see rates for CPT 49204 | ||||||
United | 49204 | $7773.00 | 1447213954 - REAGAN STREET SURGERY CENTER, LLC | 201484668 - (CA) REAGAN STREET SURGERY CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $15460.00 | 1528653037 - BASALT ORTHOPEDIC SURGERY CENTER, LLC, BOSC | 844161898 - (CO) BASALT ORTHOPEDIC SURGERY CENTER LLC | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $1339.00 | 1972711471 - NOVI SURGERY CENTER LLC, NOVI SURGERY CENTER | 201600650 - (MI) NOVI SURGERY CENTER, LLC | MI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $3240.00 | 1003272980 - PAIN CENTERS OF MINNESOTA | 352546997 - PAIN CENTERS OF MINNESOTA | MN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $8818.00 | 1881620995 - MCKINNEY SURGERY CENTER, LP, THE SURGERY CENTRE AT CRAIG RANCH | 383897811 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $5484.00 | 1891701611 - ESSEX ENDOSCOPY CENTER LLC | 223777761 - (NJ) ESSEX ENDOSCOPY CENTER LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $5019.00 | 1174587984 - ST MARKS AMBULATORY SURGERY ASSOCIATES LP, MT. OLYMPUS SURGERY CENTER | 621449273 - (UT) ST MARKS AMBULATORY SURGERY ASSOCIATES LP | UT | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $1064.00 | 1104866904 - SOUTHWESTERN EYE CENTER, SOUTHWESTERN EYE SURGICENTER-SHOW LOW | 860423068 - SOUTHWESTERN EYE CENTER, LTD. | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $898.00 | 1285673186 - BERKSHIRE COSMETIC & RECONSTRUCTIVE SURGERY CENTER INC. | 43421240 - (MA) BERKSHIRE COSMETIC RECONSTRUCTIVE SURGERY CENTER INC | MA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $3290.00 | 1568776615 - CEDAR PARK SURGERY CENTER, LLC | 272533497 - (TX) CEDAR PARK SURGERY CENTER LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $4704.00 | 1750347472 - BAYLOR SURGICARE AT NORTH DALLAS, LLC, BAYLOR SCOTT & WHITE SURGICARE-NORTH DALLAS | 752900902 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $1396.00 | 1831153527 - THE SURGICAL CENTER OF GREATER ANNAPOLIS, INC. | 521532190 - (MD) THE SURGICAL CENTER OF GREATER ANNAPOLIS INC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $2911.00 | 1134183908 - NORTH PALM BEACH COUNTY SURGERY CENTER LLC | 752424900 - (FL) NORTH PALM BEACH COUNTY SURGERY CENTER LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $4367.00 | 1770042111 - O'FALLON SURGICAL CENTER, LLC, PHYSICIANS SURGICAL CENTER | 841973218 | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 49204 | $5137.00 | 1689666596 - MENOMONEE FALLS AMBULATORY SURGERY CENTER, LLC | 391745697 - (WI) MENOMONEE FALLS AMBULATORY SURGERY CENTER | WI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 49204 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 49204 code is part of the Surgery services used for Surgical Procedures on the Digestive System. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 49204 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 49203-CPT | High | Excision Or Destruction, Open, Intra-Abdominal Tumors, Cysts Or Endometriomas, 1 Or More Peritoneal, Mesenteric, Or Retroperitoneal Primary Or Secondary Tumors; Largest Tumor 5 Cm Diameter Or Less |
| 49204-CPT | High | Excision Or Destruction Open Intra-Abdominal Tumors Cysts Or Endometriomas 1 Or More Peritoneal Mesenteric Or Retroperitoneal Primary Or Secondary Tumors;Largest Tumor 5.1-10.0 Cm Diameter |
| 49205-CPT | High | Excision Or Destruction Open Intra-Abdominal Tumors Cysts Or Endometriomas 1 Or More Peritoneal Mesenteric Or Retroperitoneal Primary Or Secondary Tumors;Largest Tumor Greater Than 10.0 Cm Diameter |
| 49250-CPT | Moderate | Umbilectomy,Omphalectomy, Excis.Of Umbil |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 49204. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 49204 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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