CPT 69000
Where the non-facility amount comes from
- Physician relative value file (PPRRVU) CMS download page PPRRVU25_JAN.csv in 2025.zip · row 13,309 hcpcs = 69000 (col 1) · status_code = A (col 4) · work_rvu = 1.5 (col 6) · pe_rvu_nonfacility = 3.81 (col 7) · pe_rvu_facility = 2.08 (col 9) · mp_rvu = 0.22 (col 11)
- Physician relative value file (PPRRVU) CMS download page PPRRVU25_JAN.csv in 2025.zip · row 11 conversion_factor = 32.3465 (col 25)
(work_rvu × work_gpci + pe_rvu × pe_gpci + mp_rvu × mp_gpci) × conversion_factor
= (1.50 × 1.000 + 3.81 × 1.000 + 0.22 × 1.000) × $32.3465 = $178.88
Where the facility amount comes from
- Physician relative value file (PPRRVU) CMS download page PPRRVU25_JAN.csv in 2025.zip · row 13,309 hcpcs = 69000 (col 1) · status_code = A (col 4) · work_rvu = 1.5 (col 6) · pe_rvu_nonfacility = 3.81 (col 7) · pe_rvu_facility = 2.08 (col 9) · mp_rvu = 0.22 (col 11)
- Physician relative value file (PPRRVU) CMS download page PPRRVU25_JAN.csv in 2025.zip · row 11 conversion_factor = 32.3465 (col 25)
(work_rvu × work_gpci + pe_rvu × pe_gpci + mp_rvu × mp_gpci) × conversion_factor
= (1.50 × 1.000 + 2.08 × 1.000 + 0.22 × 1.000) × $32.3465 = $122.92
How much did Medicare pay for CPT 69000 in Q1 2025?
Medicare paid $178.88 for CPT 69000 in the office (non-facility) setting and $122.92 in a facility under the Q1 2025 Physician Fee Schedule, effective January 2025. These are the national allowed amounts before the ~2% sequestration cut and before locality (GPCI) adjustment.
Rates by locality
The amounts above use GPCI 1.000, a national baseline no locality actually bills at. Medicare rescales every code by the local Geographic Practice Cost Indices before paying it, so what 69000 pays depends on where the service is furnished. Tap a state for its localities.
69000 non-facility rate by metro area
Highest-paying metro first. Each figure is that payment locality's own GPCI-adjusted amount.
San Jose, CA
$233.21
San Francisco, CA
$230.83
Long Island, NY
$213.16
Queens, NY
$209.35
New York City, NY
$207.16
Seattle, WA
$207.03
Washington, DC
$206.50
Boston, MA
$204.44
Northern New Jersey, NJ
$203.41
Los Angeles, CA
$202.62
San Diego, CA
$200.73
Sacramento, CA
$196.62
Miami, FL
$192.88
Baltimore, MD
$191.66
Riverside, CA
$190.25
Portland, OR
$189.98
Chicago, IL
$189.29
Suburban Chicago, IL
$189.09
Philadelphia, PA
$187.83
Fort Lauderdale, FL
$184.11
Austin, TX
$183.93
Houston, TX
$182.84
Detroit, MI
$182.41
Atlanta, GA
$179.42
Dallas, TX
$179.40
Fort Worth, TX
$178.47
St. Louis, MO
$172.92
Kansas City, MO
$172.41
New Orleans, LA
$171.98
69000 facility rate by metro area
Highest-paying metro first. Each figure is that payment locality's own GPCI-adjusted amount.
San Jose, CA
$152.91
San Francisco, CA
$151.43
Long Island, NY
$146.01
Queens, NY
$142.48
New York City, NY
$141.91
Washington, DC
$139.80
Seattle, WA
$138.76
Northern New Jersey, NJ
$137.82
Boston, MA
$137.45
Los Angeles, CA
$135.80
Miami, FL
$135.41
San Diego, CA
$134.08
Chicago, IL
$132.05
Sacramento, CA
$131.93
Baltimore, MD
$131.33
Suburban Chicago, IL
$130.44
Riverside, CA
$129.08
Philadelphia, PA
$128.91
Fort Lauderdale, FL
$128.26
Portland, OR
$128.26
Detroit, MI
$127.23
Houston, TX
$126.71
Austin, TX
$125.40
Atlanta, GA
$123.63
Dallas, TX
$123.05
Fort Worth, TX
$122.62
New Orleans, LA
$119.65
St. Louis, MO
$119.64
Kansas City, MO
$119.36
Q1 2025 amounts, computed with each locality's own GPCIs, before the ~2% sequestration cut. A state with more than one payment locality shows a range — its tile is colored by the mean across those localities, which is a shading choice, not an amount anyone is paid.
How often 69000 is billed
Across Original Medicare in CY2024, 69000 ranked #4,453 of the 7,879 CPT codes billed to Medicare that year, ranked by patients served or total allowed dollars.
2024 Medicare fee-for-service only, national totals — Medicare Advantage, Medicaid and commercial volume are excluded, so real-world use runs higher. This is a calendar-year snapshot from the CMS Physician & Other Practitioners dataset, on a different cycle from the Q1 2025 fee schedule the rates above come from.
What does 69000 cost?
Six different figures get called "the cost" of a code. They answer different questions, and only the first group comes from the CMS release.
Computed from the Q1 2025 CMS release
- Medicare allowed amount
- $178.88
- Medicare's share
- $143.10
- Patient coinsurance
- $35.78
- Limiting charge
- $195.43
The full price Medicare recognises for 69000 in the office setting. Everything below derives from it.
80% of the allowed amount, before the ~2% sequestration cut.
The remaining 20%, once the annual Part B deductible is met. Medigap or Medicaid often covers it.
The ceiling a non-participating provider can bill a patient on an unassigned claim — 109.25% of the allowed amount.
Illustrative — arithmetic on the Medicare amount, not observed prices
- Typical commercial rate
- $178.88–$447.20
- Typical cash price
- ~$178.88
Most plans land between 1× and 2.5× Medicare. Hospital-owned and concentrated markets go higher.
Many practices set a self-pay rate at or near the Medicare amount, since it saves them billing overhead — but each one sets its own, and we hold no cash-price data.
National Q1 2025 figures at GPCI 1.000. Adjust for your locality and sequestration, or see the questions below for each figure in full.
Common questions
Is $178.88 what a practice actually receives?
It's the national allowed amount — the starting point. Medicare pays 80% of it ($143.10) and the patient owes 20% coinsurance ($35.78). Sequestration trims Medicare's share by about 2%, your locality's GPCIs scale the total up or down, and the expected-payment calculator applies all three. What lands is practice revenue covering staff, space, equipment, and billing — the practice-expense RVU below is CMS's estimate of that overhead share — not clinician take-home pay.
Sources: Budget Control Act sequestration provisions; CMS Medicare Fee-for-Service payment guidance; CMS Geographic Practice Cost Index (GPCI) files; CMS Physician Fee Schedule overview (cms.gov).
Why are the facility and non-facility amounts different?
Only the practice-expense RVU changes with the setting. For 69000 it's 3.81 RVUs in the office versus 2.08 in a facility — the whole $55.96 gap between $178.88 and $122.92. In an office the practice bears the overhead, so Medicare pays more; in a hospital or ASC the facility bills its own fee, so the professional payment is lower. See facility vs non-facility.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov).
What's the limiting charge for 69000?
$195.43 in the office setting — the ceiling on what a non-participating provider can bill the patient on an unassigned claim. That's 109.25% of the $178.88 amount above. The non-participating amount is 95% of the fee schedule rate ($169.94), and the statutory cap is 115% of that. See limiting charge.
Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.
Why would a Medicare claim for 69000 be denied or paid less?
Each item below comes from a CMS indicator on this page — not general billing advice.
- 69000 carries a 10-day global period — routine post-operative care within that window is included in the surgical payment rather than paid on its own claim. See how it's computed
- Assistant at surgery: never separately payable. See billing policy
- Co-surgeons: not permitted. See billing policy
- Team surgery: not permitted. See billing policy
- Multiple procedures: standard reduction applies. See billing policy
Payer-specific coverage and documentation rules live outside these files, so a claim that clears every check here can still be denied on other grounds.
When does this rate change?
CMS publishes a fee schedule release every quarter (January, April, July, October), and each is versioned here. The 69000 rate last moved in Q1 2026 (+7.2% non-facility) — see its rate history or what changed each release, or get an email when a new release moves rates.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files.
Saw this code on your bill?
What is a 69000 visit in patient-friendly terms?
We haven't written the plain-language description for CPT 69000 yet — ask your provider's billing office what service it covers in the meantime.
I'm a patient and saw 69000 on a bill — what will I owe?
On traditional Medicare, you typically owe 20% coinsurance — about $35.78 of the office amount above — once your annual Part B deductible is met. Supplemental coverage (Medigap, Medicaid, or a retiree plan) often picks up that share. With private insurance, your cost follows your plan's negotiated rate, deductible, and copay. Your explanation of benefits (EOB) carries the exact split; the provider's bill won't.
Did I get overcharged for 69000 given my level of care?
Start from the Medicare office amount here: $178.88. Commercial plans usually pay 1× to 2.5× that — roughly $178.88 to $447.20 for 69000 — so a charge far outside that band is worth a call. Then check that the code matches the visit you remember and that the itemized bill matches your explanation of benefits (EOB). The full three-check walkthrough, including what "upcoding" looks like, is in how to check a medical bill.
What does 69000 cost with private or commercial insurance?
Every insurer negotiates its own rate, anchored to the Medicare amount. Most physician services land around 1× to 2.5× Medicare — roughly $178.88 to $447.20 for 69000 in the office setting, with hospital-owned and concentrated markets going higher. Those are arithmetic on the Medicare figure above — not observed prices, since we hold no nationwide claims database. Your explanation of benefits (EOB) carries the rate your plan actually negotiated; the market forces behind the multiple are in how to check a medical bill.
What's the cash price for 69000 if I'm paying without insurance?
Many practices set self-pay at or near the Medicare office amount — $178.88 here — because cash up front saves them billing overhead. That's a common pattern, not a figure we observed: each practice sets its own cash price and CMS has no say in it, so ask for the self-pay price before your visit. More in how to check a medical bill.
Contracted rate: % of Medicare
Commercial payer contracts usually price off the Medicare amount above ("BCBS pays 115% of Medicare"). Enter your contract's percentage below to see what 69000 pays at that rate — $178.88 is 100%.
We want to build this: store your multipliers once, and every code page shows your rate instead of Medicare's. Tell us if you'd use it →
How this amount is computed
CPT 69000 has a work RVU of 1.50, a non-facility practice expense RVU of 3.81, a facility practice expense RVU of 2.08 and a malpractice RVU of 0.22 — for total non-facility RVUs of 5.53 and total facility RVUs of 3.80 in the Q1 2025 release.
amount = (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor. National amounts use GPCI = 1.000. To price an RVU figure of your own, use the RVU-to-dollars converter.
| Component | RVU |
|---|---|
| Work RVU | 1.50 |
| Practice expense RVU (non-facility) | 3.81 |
| Practice expense RVU (facility) | 2.08 |
| Malpractice RVU | 0.22 |
Every rate combines three parts: work (the clinician’s time, skill and effort), practice expense (office overhead — higher when the service is done in a doctor’s own office), and malpractice (the share of liability-insurance cost). A blank means CMS publishes no national number for that part. Read it as unknown, and never as zero.
Billing policy
What 69000's billing-policy indicators mean. These show for every code, priced or not: a restriction like "bilateral not allowed" still matters on a carrier-priced code. See modifier amounts below for the dollar figures these support.
| Policy | Value | What it means |
|---|---|---|
| Bilateral surgery | 1 | 150% bilateral adjustment applies. Billed bilaterally (modifier 50, or on both sides), Medicare pays 150% of the single-side fee schedule amount. |
| Assistant at surgery | 1 | Never separately payable. An assistant at surgery may never be separately paid for this procedure — a statutory restriction. |
| Co-surgeons | 0 | Not permitted. Medicare does not recognize co-surgeons (modifier 62) for this procedure. |
| Team surgery | 0 | Not permitted. Medicare does not recognize a surgical team (modifier 66) for this procedure. |
| Multiple procedures | 2 | Standard reduction applies. The same standard ranking-and-reduction rule as indicator 1 applies to this procedure when billed with others on the same date. |
| Professional/technical split | 0 | No PC/TC split. This is a physician service code; the professional/technical split does not apply, and the code is billed as a single service. |
Modifier amounts: -26/TC, -50, -80/82, -AS, -62, -66
National non-facility amounts for the modifiers this code's indicators support. Single-line modifiers only. -51 (multiple-procedure reduction) depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one. Use the calculator for a locality-adjusted, sequestration-aware amount.
| Modifier | What it means | Amount |
|---|---|---|
| -26/TC | Professional/technical split | Not payable |
| -50 | Bilateral procedure (150%) | $268.32 |
| -80/82 | Assistant surgeon | Not payable |
| -AS | Assistant at surgery (non-physician) | Not payable |
| -62 | Co-surgeons, each | Not payable |
| -66 | Team surgery | Not payable |
Modifier amounts apply standard MPFS percentages (assistant surgeon 16%, co-surgeon 62.5%, bilateral 150%) to the national non-facility amount above, so its source citation covers these derived figures too. Check them against the current Medicare Claims Processing Manual before relying on them for payment.
Rate history by release
National non-facility amount for 69000 across quarterly releases. Up 7.2% since Q1 2025 · high $191.72 in Q1 2026
| Release | Status | Non-facility | Facility |
|---|---|---|---|
| Q3 2026 Jun 30, 2026 – present | A | $191.72 (0.0%) | $117.57 (0.0%) |
| Q2 2026 Mar 10, 2026 – Jun 29, 2026 | A | $191.72 (0.0%) | $117.57 (0.0%) |
| Q1 2026 Dec 29, 2025 – Mar 9, 2026 | A | $191.72 (+7.2%) | $117.57 (-4.4%) |
| Q4 2025 Sep 11, 2025 – Dec 28, 2025 | A | $178.88 (0.0%) | $122.92 (0.0%) |
| Q3 2025 Jun 5, 2025 – Sep 10, 2025 | A | $178.88 (0.0%) | $122.92 (0.0%) |
| Q2 2025 Jun 5, 2025 – Jun 4, 2025 | A | $178.88 (0.0%) | $122.92 (0.0%) |
| Q1 2025 Dec 23, 2024 – Jun 4, 2025 | A | $178.88 | $122.92 |
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Source & method
This is computed from CMS's Medicare Physician Fee Schedule Q1 2025 release (schedule pfs, effective January 2025). National amounts apply a GPCI of 1.000 and leave sequestration off. The status indicator decides payability, never the RVU values, so a blank RVU stays blank. Releases are immutable: a rate retrieved for a past quarter always reflects that release. Commercial and cash-pay figures anywhere on this page are arithmetic on the Medicare amount, using commonly cited reimbursement ranges. They're illustrative, and no nationwide claims database stands behind them. Modifier amounts apply standard MPFS percentages to this code's billing indicators. They're derived here rather than read from CMS, so confirm them against the current Claims Processing Manual before relying on them for payment.
Conversion factor $32.3465 read from the same file, row 11, column 25.
Use the (i) buttons next to each amount above for the exact row, columns, and math.
Cite this rate
This link keeps pointing at the Q1 2025 figures, even after a newer release lands.
CPT 69000 Medicare Physician Fee Schedule rate: $178.88 (Q1 2025). Localis. https://localishealth.com/cpt/69000/2025/A