Medicare Reimbursement for CPT 12042

This page summarizes the Medicare Physician Fee Schedule (PFS) allowed amount for this procedure code, shown nationally and adjusted for locality. Because CPT code descriptors are licensed by the AMA, this page refers to the code generically rather than reproducing its official description. Amounts are broken out by non-facility (office) and facility (e.g., hospital outpatient) settings, since the resources required can differ by site of service.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$304.95	$168.34
ALASKA* (AK)	$359.14	$213.65
ALABAMA (AL)	$275.09	$155.56
ARKANSAS (AR)	$271.32	$153.97
ARIZONA (AZ)	$297.18	$164.81
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$391.49	$198.87
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$399.10	$202.11
OXNARD-THOUSAND OAKS-VENTURA (CA)	$340.86	$179.39
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$342.65	$181.05
NAPA (CA)	$370.64	$190.59
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$391.83	$199.21
VALLEJO (CA)	$370.15	$190.10
BAKERSFIELD (CA)	$322.35	$172.63
CHICO (CA)	$321.44	$171.71
FRESNO (CA)	$321.44	$171.71
HANFORD-CORCORAN (CA)	$321.44	$171.71
MADERA (CA)	$321.44	$171.71
MERCED (CA)	$321.44	$171.71
MODESTO (CA)	$321.44	$171.71
REDDING (CA)	$321.44	$171.71
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$324.70	$174.98
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$336.84	$177.96
SALINAS (CA)	$335.57	$177.24
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$400.50	$203.51
SANTA CRUZ-WATSONVILLE (CA)	$346.09	$180.11
SANTA ROSA-PETALUMA (CA)	$349.56	$181.80
STOCKTON (CA)	$321.44	$171.71
VISALIA (CA)	$321.44	$171.71
YUBA CITY (CA)	$321.44	$171.71
EL CENTRO (CA)	$321.49	$171.76
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$343.09	$179.70
SAN LUIS OBISPO-PASO ROBLES (CA)	$330.21	$174.61
SANTA MARIA-SANTA BARBARA (CA)	$336.72	$177.43
REST OF CALIFORNIA (CA)	$321.44	$171.71
COLORADO (CO)	$316.91	$171.55
CONNECTICUT (CT)	$324.59	$177.46
DC + MD/VA SUBURBS (DC)	$347.31	$186.39
DELAWARE (DE)	$301.94	$166.97
FORT LAUDERDALE (FL)	$315.70	$177.31
MIAMI (FL)	$328.64	$186.43
REST OF FLORIDA (FL)	$301.01	$170.41
ATLANTA (GA)	$310.50	$171.71
REST OF GEORGIA (GA)	$284.83	$162.98
HAWAII, GUAM (HI)	$328.69	$173.37
IOWA (IA)	$281.56	$156.56
IDAHO (ID)	$283.34	$157.66
EAST ST. LOUIS (IL)	$298.78	$173.10
SUBURBAN CHICAGO (IL)	$318.83	$178.53
CHICAGO (IL)	$319.58	$182.29
REST OF ILLINOIS (IL)	$292.84	$168.11
INDIANA (IN)	$284.90	$158.26
KANSAS (KS)	$280.39	$156.89
KENTUCKY (KY)	$281.45	$160.00
NEW ORLEANS (LA)	$294.27	$165.72
REST OF LOUISIANA (LA)	$281.06	$160.16
METROPOLITAN BOSTON (MA)	$347.16	$184.05
REST OF MASSACHUSETTS (MA)	$315.19	$171.34
BALTIMORE/SURR. CNTYS (MD)	$323.68	$177.09
REST OF MARYLAND (MD)	$307.49	$169.24
SOUTHERN MAINE (ME)	$299.42	$164.04
REST OF MAINE (ME)	$284.84	$159.16
DETROIT (MI)	$304.68	$172.85
REST OF MICHIGAN (MI)	$288.49	$163.76
MINNESOTA (MN)	$303.81	$163.24
METROPOLITAN ST. LOUIS (MO)	$295.17	$165.12
METROPOLITAN KANSAS CITY (MO)	$292.27	$163.99
REST OF MISSOURI (MO)	$276.53	$158.77
MISSISSIPPI (MS)	$273.97	$156.35
MONTANA** (MT)	$304.93	$168.32
NORTH CAROLINA (NC)	$287.66	$160.20
NORTH DAKOTA** (ND)	$299.00	$162.39
NEBRASKA (NE)	$283.00	$156.91
NEW HAMPSHIRE (NH)	$312.06	$169.85
NORTHERN NJ (NJ)	$344.01	$185.54
REST OF NEW JERSEY (NJ)	$328.33	$179.15
NEW MEXICO (NM)	$290.03	$164.75
NEVADA** (NV)	$303.48	$166.73
MANHATTAN (NY)	$349.70	$190.96
NYC SUBURBS/LONG ISLAND (NY)	$357.92	$195.49
POUGHKPSIE/N NYC SUBURBS (NY)	$330.53	$180.94
QUEENS (NY)	$352.34	$190.86
REST OF NEW YORK (NY)	$291.77	$161.99
OHIO (OH)	$287.28	$162.55
OKLAHOMA (OK)	$280.88	$158.89
PORTLAND (OR)	$326.49	$174.72
REST OF OREGON (OR)	$301.16	$165.09
METROPOLITAN PHILADELPHIA (PA)	$316.89	$174.68
REST OF PENNSYLVANIA (PA)	$287.66	$162.26
PUERTO RICO (PR)	$307.04	$168.93
RHODE ISLAND (RI)	$312.33	$171.21
SOUTH CAROLINA (SC)	$287.94	$161.71
SOUTH DAKOTA** (SD)	$298.30	$161.69
TENNESSEE (TN)	$281.74	$157.56
BRAZORIA (TX)	$301.64	$166.26
DALLAS (TX)	$303.53	$167.47
GALVESTON (TX)	$302.52	$166.87
HOUSTON (TX)	$308.02	$172.36
BEAUMONT (TX)	$285.87	$161.56
FORT WORTH (TX)	$301.62	$166.92
AUSTIN (TX)	$315.83	$171.29
REST OF TEXAS (TX)	$293.57	$163.93
UTAH (UT)	$291.68	$163.27
VIRGINIA (VA)	$298.53	$164.25
VIRGIN ISLANDS (VI)	$307.04	$168.93
VERMONT (VT)	$297.96	$162.72
SEATTLE (KING CNTY) (WA)	$353.99	$186.36
REST OF WASHINGTON (WA)	$314.55	$170.70
WISCONSIN (WI)	$289.44	$158.57
WEST VIRGINIA (WV)	$282.53	$163.82
WYOMING** (WY)	$302.34	$165.74

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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 billed, to reflect local cost differences. The adjusted RVUs are summed and multiplied by the annual national conversion factor to produce a dollar allowed amount. Non-facility and facility settings use different practice-expense RVUs, because the physician's overhead costs are lower when the service is performed in a facility that bears its own costs, which is why the two allowed amounts differ.

RVUs — work 2.72, practice expense 6.11 (non-facility) / 2.02 (facility), malpractice 0.3 — × the locality GPCIs × the 2026 conversion factor of $33.40.

Good to know

All figures are estimates only, not a guarantee of payment.
Medicare typically pays 80% of the allowed amount after the patient meets their Part B deductible; the patient or secondary payer is generally responsible for the remainder.
Actual payment can vary by locality, applicable modifiers, claims-processing adjustments, sequestration, and annual budget-neutrality changes to RVUs or the conversion factor.
Always verify current rates and coverage policy with your Medicare Administrative Contractor (MAC) before billing or appealing a claim.

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 (such as a hospital) incurs many of the overhead costs separately, so the physician payment reflects less of that overhead.

Why might the amount I see on a remittance advice differ from this estimate?

Local GPCIs, applied modifiers, sequestration reductions, and mid-year or annual adjustments to RVUs or the conversion factor can all change the final paid amount from the national baseline shown here.

Does this page tell me what the patient will owe?

No. This page shows the Medicare-allowed amount estimate only. Patient responsibility depends on deductible status, coinsurance (typically 20%), and any secondary insurance.

Can I use this figure to predict payment for a specific claim?

Treat it as a general estimate. For claim-specific accuracy, confirm the locality-adjusted rate and any applicable modifiers with your MAC.

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.