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Medicare Physician Fee Schedule · Q4 2026 release

CPT 92004 in Houston, TX

New patient eye examination, comprehensive in ZIPs including 77002, 77019, and 77024

92004 Q4 2026 · Houston, TX flag04412-18
Locality-adjusted allowed amount
$150.01
in a doctor’s own office or clinic

100.2% of the $149.64 national baseline

( Work1.82 × 1.008 + Practice exp.2.62 × 0.993 + Malpractice0.04 × 1.376 ) × Conv. factor$33.4009 = $150.01

The Medicare allowed amount is $150.01 in the Office (non-facility) setting and $78.70 in a facility, under the Q4 2026 Physician Fee Schedule. This is the fee schedule amount before sequestration and before any deductible or coinsurance is applied—not necessarily what a specific claim pays.

Q4 2026 · Locality 04412-18 · Participating · Whole service · Sequestration excluded

CMS sources and method · Calculation inputs

Calculate with this locality Check service-location ZIP

What Medicare locality is Houston, TX in? Copy link

Houston, TX is in CMS payment locality Houston (04412-18). The same amount applies everywhere in it.

Confirm the locality before using this amount. A split ZIP needs ZIP+4 for an exact match.

ZIP codes in this payment locality (243)

The CMS ZIP-to-locality crosswalk maps 243 ZIP codes to this payment locality. Use this amount only after you confirm the service location is in this locality. Of these, 12 span more than one locality and need ZIP+4 for an exact match.

77001 77002 77003 77004 77005 77006 77007 77008 77009 77010 77011 77012 77013 77014 77015 77016 77017 77018 77019 77020 77021 77022 77023 77024 77025 77026 77027 77028 77029 77030 77031 77032 77033 77034 77035 77036 77037 77038 77039 77040 77041 77042 77043 77044 77045 77046 77047 77048 77049 77050 77051 77052 77054 77055 77056 77057 77058 77059 77060 77061 77062 77063 77064 77065 77066 77067 77068 77069 77070 77071 77072 77073 77074 77075 77076 77077 77078 77079 77080 77081 77082 77083 77084 77085 77086 77087 77088 77089 77090 77091 77092 77093 77094 77095 77096 77097 77098 77099 77201 77202

143 more ZIP codes map to this locality. The Houston, TX locality page lists the full set.

Which ZIP codes does the Houston, TX rate for 92004 cover?

The CMS ZIP-to-locality crosswalk maps 243 ZIP codes to this payment locality, and 92004 has the same amount in every one of them. Examples include 77001, 77002, 77003, 77004, 77005, 77006. Of these, 12 span more than one payment locality and need ZIP+4 for an exact match.

How locality affects the amount Copy link

Office (non-facility) · Q4 2026 · Participating · Whole service

Houston, TX (this locality)
$150.01
National PFS baseline (GPCI 1.000)
$149.64

Each of this locality's geographic practice cost indices (GPCIs) scales one RVU component before the conversion factor is applied. Together they put Houston, TX 0.2% above the national baseline.

Work GPCI
1.008
Practice expense GPCI
0.993
Malpractice GPCI
1.376
2026 conversion factor
$33.4009
Why is the 92004 rate in Houston, TX different from the national amount?

The national figure is a GPCI 1.000 baseline, not an amount any provider is paid. This locality's geographic practice cost indices—work 1.008, practice expense 0.993, malpractice 1.376—scale each RVU component before the conversion factor is applied, which is why the Houston, TX amount is higher than the $149.64 baseline.

Formula and inputs Copy link

For the office (non-facility) amount, each of 92004's RVU components is multiplied by its Houston, TX GPCI; the products are summed and multiplied by the conversion factor.

Code
92004
DOS
Not selected; uses this release’s rates
Locality
HOUSTON (TX)
Setting
Office (non-facility)
Participation
Participating provider
Modifiers
None
Units
1
Release
Q4 2026, revision 2
Sequestration
Shown separately from the allowed amount

Formula

(work_rvu × work_gpci + pe_rvu × pe_gpci + mp_rvu × mp_gpci) × conversion_factor

Localis calculated this from CMS’s published inputs. Select an underlined value to see where it comes from.

RVU × GPCI components of Houston, TX allowed amount for 92004
Component RVU × GPCI = Adjusted
Work 1.82 × 1.008 1.8346
Practice expense · Office (non-facility) 2.62 × 0.993 2.6017
Malpractice 0.04 × 1.376 0.0550
Sum of adjusted RVUs 4.4913
× 33.4009 conversion factor = formula amount $150.01

Component subtotals show four decimals. The formula amount is rounded to cents before any later adjustment.

  1. Locality-adjusted allowed amount $150.01

    After applicable fee-schedule adjustments; sequestration excluded

Citations

  • Supplies the RVUs and PFS status for this code and component.

    Physician relative value file (PPRRVU)

    Q4 2026 · revision 2

    Latest revision of this release

    Release period: October 1 – December 31, 2026

    Record details PPRRVU2026_Oct_nonQPP.csv in rvu26d-updated-08-26-2026.zip (row 11,660)
    hcpcs (col 1)
    92004
    modifier (col 2)
    blank
    status_code (col 4)
    A
    work_rvu (col 6)
    1.82
    pe_rvu_nonfacility (col 7)
    2.62
    pe_rvu_facility (col 9)
    0.47
    mp_rvu (col 11)
    0.04

    SHA-256: 4d0d3f19bd954ffc0f5b8439169d267da023d4f6911f4539bb6e98723cb1a626

    Original source file

  • Supplies the geographic adjustment factors for this locality.

    Geographic practice cost indices (GPCI)

    Q4 2026 · revision 2

    Latest revision of this release

    Release period: October 1 – December 31, 2026

    Record details GPCI2026.csv in rvu26d-updated-08-26-2026.zip (row 102)
    mac (col 1)
    04412
    locality_code (col 3)
    18
    work_gpci (col 5)
    1.008
    pe_gpci (col 6)
    0.993
    mp_gpci (col 7)
    1.376

    SHA-256: 7850e2987d12e46930e49033f96829b5ae11f60dd1f19965329b38cf08b05264

    Original source file

  • Supplies the dollar conversion factor used in the formula.

    Physician relative value file (PPRRVU)

    Q4 2026 · revision 2

    Latest revision of this release

    Release period: October 1 – December 31, 2026

    Record details PPRRVU2026_Oct_nonQPP.csv in rvu26d-updated-08-26-2026.zip (row 11)
    conversion_factor (col 26)
    33.4009

    SHA-256: 4d0d3f19bd954ffc0f5b8439169d267da023d4f6911f4539bb6e98723cb1a626

    Original source file

Facility vs. Office (non-facility) Copy link

In a facility (hospital outpatient department or ASC), the allowed amount for 92004 in Houston, TX is $78.70, versus $150.01 in the Office (non-facility) setting. Only the practice-expense RVU changes with the setting: the facility bills its own fee for overhead, so the professional amount is lower. See which setting applies to your place of service.

What is the Facility amount for 92004 in Houston, TX?

$78.70 in a facility, versus $150.01 in the Office (non-facility) setting—a $71.31 difference. Only the practice-expense RVU changes with the setting: in the Office (non-facility) setting the practice carries the overhead, so the professional amount is higher; in a hospital or ASC the facility bills its own fee.

Participating, non-participating and limiting charge Copy link

All figures are for the office (non-facility) setting in Houston, TX. Medicare pays part of the allowed amount and the patient pays the rest; the rows below show each figure. See how the limiting charge and sequestration are derived.

Participation and payment-split amounts for 92004 in Houston, TX
Participating allowed amount The fee schedule amount a participating provider accepts as payment in full. $150.01
Non-participating allowed amount 95% of the participating amount. $142.51
Limiting charge Ceiling a non-participating provider may bill the patient on an unassigned claim—115% of the non-participating amount. $163.89
Medicare share 80% of the allowed amount, once the annual Part B deductible is met. $120.01
Patient coinsurance The remaining 20%. $30.00
Sequestration adjustment Reduces only Medicare's share—never the allowed amount or the patient's coinsurance. $2.40
Net Medicare payment Medicare's share after the sequestration reduction. $117.61
What is the non-participating amount and limiting charge for 92004 in Houston, TX?

A non-participating provider is paid $142.51—95% of the $150.01 participating fee schedule amount. On an unassigned claim the limiting charge caps what the patient can be billed at $163.89, which is 115% of the non-participating amount.

How much of the Houston, TX 92004 rate does Medicare actually pay?

Medicare pays 80% of the allowed amount ($120.01) once the annual Part B deductible is met, and the beneficiary owes 20% ($30.00). Sequestration reduces Medicare's share by about 2% ($2.40), leaving $117.61. Sequestration never changes the allowed amount itself, which is why it is shown separately here.

Contracted rate: % of Medicare in Houston, TX Copy link

Commercial contracts are often written as a percentage of the Medicare fee schedule. The part that gets misread is which Medicare amount: a contract benchmarked to the fee schedule prices off this locality's allowed amount—$150.01 in the office (non-facility) setting—not the $149.64 national baseline.

Opens the calculator set to Houston, TX and your selected setting, where you can also compare what a payer paid against the expected amount. See how to find your contract's actual percentage.

Compare 92004 in nearby payment localities

Payment localities in the same region as Houston, TX, nearest first. Each amount is that locality's own GPCI-adjusted Office (non-facility) figure for 92004. Neighboring localities often differ.

92004 allowed amount in payment localities near Houston, TX
Metro Allowed amount vs. Houston, TX
San Antonio, TX $145.04 -3.3%
Austin, TX $154.68 +3.1%
Dallas, TX $149.64 -0.2%
Fort Worth, TX $148.79 -0.8%
New Orleans, LA $144.65 -3.6%
Oklahoma City, OK $139.97 -6.7%

Every payment locality nationwide is on the CPT 92004 rate map.

Other codes priced in Houston, TX Copy link

Office (non-facility) allowed amounts in this same payment locality, Q4 2026.

Other curated codes and their allowed amounts in Houston, TX
Code and service Allowed vs. national
92014 Full Eye Exam, Returning Patient $127.59 +0.3%
92012 Established Patient Eye Examination, Intermediate $90.73 +0.2%
67028 Intravitreal Medication Injection $115.54 +1.1%
92134 Retina Scan $32.91 +0.5%
99213 Routine Follow-Up Office Visit $96.33 +1.2%
99214 Long Follow-Up Office Visit $137.41 +1.3%
66984 Cataract Surgery $469.86 +1.6%
99204 Long New Patient Office Visit $180.49 +1.8%
99212 Brief Follow-Up Office Visit $60.16 +1.2%
99215 Longest Follow-Up Office Visit $195.13 +1.4%
97110 Physical Therapy Exercises $29.21 +0.5%
99203 New Patient Office Visit $119.60 +1.7%

Source & method Copy link

Computed from the CMS Medicare Physician Fee Schedule Q4 2026 release: this code's RVUs from the relative value file, multiplied by payment locality 04412-18's GPCIs, then by the 2026 conversion factor of $33.4009. ZIP coverage from the CMS ZIP-to-locality crosswalk, Q4 2026 release. Past releases are never edited, so an amount for an earlier quarter always matches what CMS published for it. Coverage and coding correctness are outside this calculation.

Physician relative value file (Q4 2026) · rvu26d-updated-08-26-2026.zip (PPRRVU2026_Oct_nonQPP.csv row 11,660)
Geographic practice cost indices (Q4 2026) · rvu26d-updated-08-26-2026.zip (GPCI2026.csv row 102)
ZIP code to carrier locality crosswalk (Q4 2026) · zip-code-carrier-locality-file-updated-08-13-2026.zip (ZIP5_OCT2026.txt)

Working a claim with an earlier date of service? The calculator prices 92004 in Houston, TX against the release in effect on that date. Dates in the last 12 months don't need an account; older dates of service need a free account.

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