Medicare Reimbursement for CPT 12016

CPT 12016 is a procedure code used for physician billing; the exact clinical descriptor is licensed by the AMA and not reproduced here. This page displays the Medicare Physician Fee Schedule (PFS) estimated allowed amount for this code, shown nationally and adjustable by locality, with separate figures for non-facility (e.g., office) and facility (e.g., hospital) settings.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$267.54	$122.25
ALASKA* (AK)	$312.38	$157.64
ALABAMA (AL)	$238.70	$111.57
ARKANSAS (AR)	$235.10	$110.29
ARIZONA (AZ)	$259.65	$118.86
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$329.70	$124.84
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$335.56	$126.05
OXNARD-THOUSAND OAKS-VENTURA (CA)	$291.42	$119.68
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$293.55	$121.67
NAPA (CA)	$313.89	$122.39
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$330.40	$125.53
VALLEJO (CA)	$312.89	$121.39
BAKERSFIELD (CA)	$276.59	$117.35
CHICO (CA)	$274.93	$115.69
FRESNO (CA)	$274.93	$115.69
HANFORD-CORCORAN (CA)	$274.93	$115.69
MADERA (CA)	$274.93	$115.69
MERCED (CA)	$274.93	$115.69
MODESTO (CA)	$274.93	$115.69
REDDING (CA)	$274.93	$115.69
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$281.47	$122.23
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$287.30	$118.33
SALINAS (CA)	$286.23	$117.83
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$338.39	$128.88
SANTA CRUZ-WATSONVILLE (CA)	$294.32	$117.78
SANTA ROSA-PETALUMA (CA)	$297.18	$118.76
STOCKTON (CA)	$274.93	$115.69
VISALIA (CA)	$274.93	$115.69
YUBA CITY (CA)	$274.93	$115.69
EL CENTRO (CA)	$275.03	$115.79
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$292.18	$118.41
SAN LUIS OBISPO-PASO ROBLES (CA)	$281.81	$116.32
SANTA MARIA-SANTA BARBARA (CA)	$287.09	$117.67
REST OF CALIFORNIA (CA)	$274.93	$115.69
COLORADO (CO)	$274.36	$119.77
CONNECTICUT (CT)	$285.88	$129.40
DC + MD/VA SUBURBS (DC)	$303.03	$131.87
DELAWARE (DE)	$264.00	$120.45
FORT LAUDERDALE (FL)	$286.08	$138.90
MIAMI (FL)	$305.25	$154.00
REST OF FLORIDA (FL)	$270.75	$131.85
ATLANTA (GA)	$274.46	$126.84
REST OF GEORGIA (GA)	$254.17	$124.57
HAWAII, GUAM (HI)	$280.88	$115.68
IOWA (IA)	$241.66	$108.71
IDAHO (ID)	$244.00	$110.33
EAST ST. LOUIS (IL)	$275.40	$141.73
SUBURBAN CHICAGO (IL)	$288.20	$138.98
CHICAGO (IL)	$295.34	$149.32
REST OF ILLINOIS (IL)	$265.09	$132.44
INDIANA (IN)	$245.39	$110.70
KANSAS (KS)	$242.08	$110.73
KENTUCKY (KY)	$248.05	$118.88
NEW ORLEANS (LA)	$260.87	$124.15
REST OF LOUISIANA (LA)	$248.29	$119.70
METROPOLITAN BOSTON (MA)	$299.91	$126.43
REST OF MASSACHUSETTS (MA)	$273.28	$120.28
BALTIMORE/SURR. CNTYS (MD)	$285.44	$129.54
REST OF MARYLAND (MD)	$268.66	$121.62
SOUTHERN MAINE (ME)	$258.58	$114.60
REST OF MAINE (ME)	$247.04	$113.37
DETROIT (MI)	$275.92	$135.71
REST OF MICHIGAN (MI)	$256.25	$123.60
MINNESOTA (MN)	$257.84	$108.33
METROPOLITAN ST. LOUIS (MO)	$259.90	$121.58
METROPOLITAN KANSAS CITY (MO)	$257.31	$120.88
REST OF MISSOURI (MO)	$244.93	$119.69
MISSISSIPPI (MS)	$239.98	$114.89
MONTANA** (MT)	$267.50	$122.21
NORTH CAROLINA (NC)	$249.47	$113.91
NORTH DAKOTA** (ND)	$255.44	$110.14
NEBRASKA (NE)	$242.55	$108.44
NEW HAMPSHIRE (NH)	$271.55	$120.30
NORTHERN NJ (NJ)	$300.02	$131.48
REST OF NEW JERSEY (NJ)	$287.72	$129.06
NEW MEXICO (NM)	$258.36	$125.12
NEVADA** (NV)	$264.30	$118.86
MANHATTAN (NY)	$310.98	$142.15
NYC SUBURBS/LONG ISLAND (NY)	$320.82	$148.07
POUGHKPSIE/N NYC SUBURBS (NY)	$290.94	$131.85
QUEENS (NY)	$311.24	$139.51
REST OF NEW YORK (NY)	$253.49	$115.46
OHIO (OH)	$253.79	$121.13
OKLAHOMA (OK)	$245.88	$116.13
PORTLAND (OR)	$281.48	$120.06
REST OF OREGON (OR)	$260.85	$116.14
METROPOLITAN PHILADELPHIA (PA)	$279.60	$128.35
REST OF PENNSYLVANIA (PA)	$253.30	$119.92
PUERTO RICO (PR)	$269.00	$122.10
RHODE ISLAND (RI)	$272.28	$122.19
SOUTH CAROLINA (SC)	$252.33	$118.07
SOUTH DAKOTA** (SD)	$254.01	$108.72
TENNESSEE (TN)	$243.55	$111.48
BRAZORIA (TX)	$262.32	$118.33
DALLAS (TX)	$264.79	$120.08
GALVESTON (TX)	$263.61	$119.34
HOUSTON (TX)	$274.78	$130.50
BEAUMONT (TX)	$251.70	$119.48
FORT WORTH (TX)	$263.46	$120.20
AUSTIN (TX)	$274.67	$120.95
REST OF TEXAS (TX)	$257.41	$119.52
UTAH (UT)	$255.86	$119.29
VIRGINIA (VA)	$258.83	$116.01
VIRGIN ISLANDS (VI)	$269.00	$122.10
VERMONT (VT)	$255.88	$112.04
SEATTLE (KING CNTY) (WA)	$304.49	$126.21
REST OF WASHINGTON (WA)	$272.28	$119.29
WISCONSIN (WI)	$246.72	$107.53
WEST VIRGINIA (WV)	$255.36	$129.10
WYOMING** (WY)	$262.24	$116.95

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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 risk. Each RVU component is adjusted by Geographic Practice Cost Indices (GPCIs) specific to the locality where the service is furnished, to account for regional cost differences. The adjusted RVUs are summed and multiplied by the annual national conversion factor to produce the allowed amount. Practice-expense RVUs differ between non-facility and facility settings because overhead costs (equipment, supplies, staff) are treated differently depending on where the service is performed.

RVUs — work 2.61, practice expense 4.79 (non-facility) / 0.44 (facility), malpractice 0.61 — × 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 beneficiary or secondary insurer is responsible for the rest.
Actual payment can vary by locality, applicable modifiers, sequestration reductions, and annual budget-neutrality adjustments.
Always verify current rates and coverage rules with your Medicare Administrative Contractor (MAC).

Frequently asked

Why is the facility amount different from the non-facility amount?

Facility settings (like hospitals) typically have lower practice-expense RVUs because overhead costs such as equipment and staffing are covered separately by the facility's own payment, whereas non-facility settings bundle those costs into the physician payment.

Does this amount reflect what Medicare will actually pay?

No — it is an estimate. Medicare generally pays 80% of the allowed amount after the deductible, and actual reimbursement depends on locality, modifiers, and other adjustments like sequestration.

Why can't you show the CPT code description?

CPT descriptors are copyrighted and licensed by the American Medical Association, so this page refers to the code generically rather than reproducing its official text.

Why do GPCIs matter for this estimate?

GPCIs adjust the RVUs to reflect local cost-of-living and practice-cost differences, so the same code can have different allowed amounts depending on the locality where the service is billed.

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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.