Medicare Reimbursement for CPT 11042

This page covers a specific CPT procedure code used in Medicare billing. It shows the Medicare Physician Fee Schedule (PFS) allowed amount at the national level and by locality, with separate figures for non-facility and facility settings.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$132.60	$55.78
ALASKA* (AK)	$153.23	$71.41
ALABAMA (AL)	$118.78	$51.56
ARKANSAS (AR)	$117.03	$51.04
ARIZONA (AZ)	$129.01	$54.57
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$172.38	$64.06
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$175.81	$65.03
OXNARD-THOUSAND OAKS-VENTURA (CA)	$149.27	$58.46
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$149.97	$59.09
NAPA (CA)	$162.90	$61.65
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$172.53	$64.21
VALLEJO (CA)	$162.69	$61.44
BAKERSFIELD (CA)	$140.70	$56.50
CHICO (CA)	$140.31	$56.12
FRESNO (CA)	$140.31	$56.12
HANFORD-CORCORAN (CA)	$140.31	$56.12
MADERA (CA)	$140.31	$56.12
MERCED (CA)	$140.31	$56.12
MODESTO (CA)	$140.31	$56.12
REDDING (CA)	$140.31	$56.12
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$141.72	$57.53
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$147.34	$57.99
SALINAS (CA)	$146.79	$57.75
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$176.41	$65.63
SANTA CRUZ-WATSONVILLE (CA)	$151.81	$58.47
SANTA ROSA-PETALUMA (CA)	$153.35	$59.01
STOCKTON (CA)	$140.31	$56.12
VISALIA (CA)	$140.31	$56.12
YUBA CITY (CA)	$140.31	$56.12
EL CENTRO (CA)	$140.34	$56.14
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$150.32	$58.44
SAN LUIS OBISPO-PASO ROBLES (CA)	$144.42	$56.92
SANTA MARIA-SANTA BARBARA (CA)	$147.36	$57.79
REST OF CALIFORNIA (CA)	$140.31	$56.12
COLORADO (CO)	$138.16	$56.42
CONNECTICUT (CT)	$141.52	$58.79
DC + MD/VA SUBURBS (DC)	$151.86	$61.37
DELAWARE (DE)	$131.18	$55.28
FORT LAUDERDALE (FL)	$137.35	$59.53
MIAMI (FL)	$143.16	$63.19
REST OF FLORIDA (FL)	$130.58	$57.14
ATLANTA (GA)	$135.10	$57.05
REST OF GEORGIA (GA)	$123.12	$54.59
HAWAII, GUAM (HI)	$143.86	$56.51
IOWA (IA)	$121.86	$51.57
IDAHO (ID)	$122.67	$51.99
EAST ST. LOUIS (IL)	$129.36	$58.69
SUBURBAN CHICAGO (IL)	$138.76	$59.87
CHICAGO (IL)	$138.93	$61.73
REST OF ILLINOIS (IL)	$126.74	$56.60
INDIANA (IN)	$123.40	$52.18
KANSAS (KS)	$121.28	$51.83
KENTUCKY (KY)	$121.63	$53.33
NEW ORLEANS (LA)	$127.56	$55.27
REST OF LOUISIANA (LA)	$121.43	$53.45
METROPOLITAN BOSTON (MA)	$152.00	$60.27
REST OF MASSACHUSETTS (MA)	$137.31	$56.41
BALTIMORE/SURR. CNTYS (MD)	$141.13	$58.70
REST OF MARYLAND (MD)	$133.72	$55.98
SOUTHERN MAINE (ME)	$130.14	$54.01
REST OF MAINE (ME)	$123.32	$52.64
DETROIT (MI)	$132.24	$58.10
REST OF MICHIGAN (MI)	$124.85	$54.71
MINNESOTA (MN)	$132.31	$53.27
METROPOLITAN ST. LOUIS (MO)	$128.02	$54.89
METROPOLITAN KANSAS CITY (MO)	$126.67	$54.54
REST OF MISSOURI (MO)	$119.31	$53.09
MISSISSIPPI (MS)	$118.19	$52.05
MONTANA** (MT)	$132.59	$55.77
NORTH CAROLINA (NC)	$124.63	$52.96
NORTH DAKOTA** (ND)	$130.02	$53.20
NEBRASKA (NE)	$122.55	$51.64
NEW HAMPSHIRE (NH)	$135.98	$56.00
NORTHERN NJ (NJ)	$150.24	$61.13
REST OF NEW JERSEY (NJ)	$143.12	$59.23
NEW MEXICO (NM)	$125.55	$55.10
NEVADA** (NV)	$131.97	$55.07
MANHATTAN (NY)	$152.72	$63.45
NYC SUBURBS/LONG ISLAND (NY)	$156.47	$65.13
POUGHKPSIE/N NYC SUBURBS (NY)	$144.06	$59.94
QUEENS (NY)	$154.00	$63.20
REST OF NEW YORK (NY)	$126.54	$53.55
OHIO (OH)	$124.33	$54.19
OKLAHOMA (OK)	$121.41	$52.81
PORTLAND (OR)	$142.62	$57.27
REST OF OREGON (OR)	$130.93	$54.42
METROPOLITAN PHILADELPHIA (PA)	$137.95	$57.97
REST OF PENNSYLVANIA (PA)	$124.53	$54.01
PUERTO RICO (PR)	$133.59	$55.92
RHODE ISLAND (RI)	$135.91	$56.55
SOUTH CAROLINA (SC)	$124.69	$53.71
SOUTH DAKOTA** (SD)	$129.72	$52.90
TENNESSEE (TN)	$121.90	$52.07
BRAZORIA (TX)	$131.05	$54.92
DALLAS (TX)	$131.90	$55.38
GALVESTON (TX)	$131.45	$55.16
HOUSTON (TX)	$133.83	$57.54
BEAUMONT (TX)	$123.70	$53.79
FORT WORTH (TX)	$131.00	$55.25
AUSTIN (TX)	$137.71	$56.43
REST OF TEXAS (TX)	$127.31	$54.40
UTAH (UT)	$126.43	$54.21
VIRGINIA (VA)	$129.70	$54.18
VIRGIN ISLANDS (VI)	$133.59	$55.92
VERMONT (VT)	$129.50	$53.45
SEATTLE (KING CNTY) (WA)	$155.13	$60.87
REST OF WASHINGTON (WA)	$137.05	$56.16
WISCONSIN (WI)	$125.58	$51.99
WEST VIRGINIA (WV)	$121.96	$55.20
WYOMING** (WY)	$131.47	$54.65

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Maximum units per day (MUE)

Medicare’s Medically Unlikely Edit caps this code at 1 unit per patient per day — Date of Service Edit: Policy. Units above the MUE are denied; some MUEs can be exceeded only with appropriate documentation and modifiers where policy allows.

How the amount is calculated

Medicare's PFS amount is built from three Relative Value Units (RVUs) assigned to a code: physician work, practice expense, and malpractice. Each RVU component is adjusted by the Geographic Practice Cost Indices (GPCIs) for the specific locality where the service is billed, reflecting local cost differences. The adjusted RVUs are summed and multiplied by the annual conversion factor (a dollar figure set by CMS) to produce the allowed amount. Practice expense RVUs differ between non-facility settings (e.g., a physician's office, which bears more overhead) and facility settings (e.g., a hospital, where the facility itself absorbs many costs), which is why the two amounts differ for the same code.

RVUs — work 0.98, practice expense 2.86 (non-facility) / 0.56 (facility), malpractice 0.13 — × the locality GPCIs × the 2026 conversion factor of $33.40.

Good to know

This is an estimate only, not a guarantee of payment.
Medicare typically pays 80% of the allowed amount after the annual Part B deductible is met; the patient or secondary payer is generally responsible for the remainder.
Actual payment can vary by locality, applicable modifiers, claim-level adjustments, sequestration, and annual budget-neutrality adjustments to RVUs or the conversion factor.
Always verify current rates and coverage rules with your Medicare Administrative Contractor (MAC) before billing or appealing a denial.

Frequently asked

Why does the facility amount differ from the non-facility amount for this code?

The practice expense RVU is lower in the facility setting because the facility (e.g., hospital) bears more of the overhead costs, while in a non-facility setting (e.g., physician office) the billing provider absorbs those costs, resulting in a higher practice expense RVU and allowed amount.

Does this amount change by location?

Yes. Each locality has its own GPCI values for work, practice expense, and malpractice, which adjust the RVUs before the conversion factor is applied, so the final allowed amount can vary from one locality to another.

Will Medicare pay this full amount?

No. Medicare generally reimburses 80% of the allowed amount after the patient's deductible has been met; the displayed figure is the total allowed amount, not the portion Medicare actually pays.

Can modifiers or other factors change this fee?

Yes. Modifiers, multiple-procedure reductions, sequestration, and annual budget-neutrality adjustments can all affect the final paid amount, so this figure should be treated as a reference estimate.

More free billing tools: all Medicare fees · fee calculator · denial code decoder

Estimated Medicare Physician Fee Schedule amount. Medicare generally pays 80% after the deductible; actual amounts vary by locality, modifiers, sequestration, and annual updates. Verify with your MAC.