CPT 92004 Fee Schedule
Last Updated: August 2025
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Medicine Services and Procedures • Ophthalmology Services and Procedures |
| Common Place of Service | • 11 - Office • None |
| Common Modifiers | • None • 25 - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service • 57 - An evaluation and management (E/M) service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service |
| Complexity Level | Moderate |
National average reimbursement for CPT 92004 by major payers:
$136.57
$174.07
$179.83
$198.09
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Related Codes
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 92004. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 92004 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.
CPT 92004 vs. Other Ophthalmology Services and Procedures Codes
The CPT 92004 code is part of the Medicine Services and Procedures services used for Ophthalmology Services and Procedures. 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 92004 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.
| CPT Code | Complexity Level | Description |
|---|---|---|
| 92002 | Low | Ophthalmological Services: Medical Examination And Evaluation With Initiation Of Diagnostic And Treatment Program; Intermediate, New Patient |
| 92004 | Low | Ophthalmological Services: Medical Examination And Evaluation With Initiation Of Diagnostic And Treatment Program; Comprehensive, New Patient, 1 Or More Visits |
| 92012 | Low | Ophthalmological Services: Medical Examination And Evaluation, With Initiation Or Continuation Of Diagnostic And Treatment Program; Intermediate, Established Patient |
| 92014 | Low | Ophthalmological Services: Medical Examination And Evaluation, With Initiation Or Continuation Of Diagnostic And Treatment Program; Comprehensive, Established Patient, 1 Or More Visits |
See what providers are getting paid in 2025 for 92004:
CPT 92004 Fee Schedule & Reimbursement Rates
The CPT 92004 fee schedule varies by payer type. Below are Medicare rates for 2025 and average in-network rates by state across major payers:
| Code | Medicare Rate | Avg. BCBS National Rate | More Info |
|---|---|---|---|
| 92002 | $84.55 | $81.44 | |
| 92004 | $148.46 | $136.57 | |
| 92012 | $88.88 | $84.31 | |
| 92014 | $125.49 | $116.45 | |
| 92015 | $18.97 | $26.62 | |
| 92018 | $136.81 | $169.57 |
Reimbursement rates depend on provider contracts, region, and payer. Always verify rates with your insurance provider or medical billing department.
What is Price Transparency?
The Price Transparency Rule is a federal law that took effect in July 2022, requiring all commercial payers to publicly disclose their prices through machine-readable files (MRFs). This landmark regulation mandates that insurance companies make healthcare costs transparent to the public.
Our data comes directly from these insurer-posted MRFs, ensuring compliance with the Price Transparency Rule. While PayerPrice is working toward a future where providers and payers collaborate for 100% upfront price certainty, it's important to acknowledge that data limitations and occasional errors may exist.
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