Medicare Reimbursement for CPT 12054

CPT 12054 is a procedure code reported to Medicare for professional services; the specific clinical descriptor is licensed by the AMA and is not reproduced here. This page shows the Medicare Physician Fee Schedule (PFS) allowed amount for 2026, both at the national level 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)	$391.46	$197.07
ALASKA* (AK)	$457.69	$250.66
ALABAMA (AL)	$351.50	$181.41
ARKANSAS (AR)	$346.46	$179.48
ARIZONA (AZ)	$380.93	$192.56
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$499.30	$225.21
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$508.87	$228.55
OXNARD-THOUSAND OAKS-VENTURA (CA)	$435.64	$205.87
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$438.08	$208.11
NAPA (CA)	$473.10	$216.89
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$499.88	$225.78
VALLEJO (CA)	$472.27	$216.06
BAKERSFIELD (CA)	$411.97	$198.92
CHICO (CA)	$410.50	$197.45
FRESNO (CA)	$410.50	$197.45
HANFORD-CORCORAN (CA)	$410.50	$197.45
MADERA (CA)	$410.50	$197.45
MERCED (CA)	$410.50	$197.45
MODESTO (CA)	$410.50	$197.45
REDDING (CA)	$410.50	$197.45
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$416.02	$202.96
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$430.12	$204.04
SALINAS (CA)	$428.51	$203.21
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$511.24	$230.92
SANTA CRUZ-WATSONVILLE (CA)	$441.96	$205.77
SANTA ROSA-PETALUMA (CA)	$446.37	$207.66
STOCKTON (CA)	$410.50	$197.45
VISALIA (CA)	$410.50	$197.45
YUBA CITY (CA)	$410.50	$197.45
EL CENTRO (CA)	$410.59	$197.53
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$438.14	$205.64
SAN LUIS OBISPO-PASO ROBLES (CA)	$421.70	$200.29
SANTA MARIA-SANTA BARBARA (CA)	$429.99	$203.33
REST OF CALIFORNIA (CA)	$410.50	$197.45
COLORADO (CO)	$405.77	$198.93
CONNECTICUT (CT)	$417.37	$208.01
DC + MD/VA SUBURBS (DC)	$445.91	$216.91
DELAWARE (DE)	$387.18	$195.12
FORT LAUDERDALE (FL)	$408.61	$211.69
MIAMI (FL)	$428.19	$225.82
REST OF FLORIDA (FL)	$388.56	$202.72
ATLANTA (GA)	$399.39	$201.89
REST OF GEORGIA (GA)	$366.59	$193.19
HAWAII, GUAM (HI)	$419.98	$198.95
IOWA (IA)	$359.04	$181.17
IDAHO (ID)	$361.64	$182.80
EAST ST. LOUIS (IL)	$387.89	$209.05
SUBURBAN CHICAGO (IL)	$412.44	$212.80
CHICAGO (IL)	$415.62	$220.25
REST OF ILLINOIS (IL)	$378.38	$200.90
INDIANA (IN)	$363.68	$183.48
KANSAS (KS)	$358.00	$182.27
KENTUCKY (KY)	$361.09	$188.28
NEW ORLEANS (LA)	$378.40	$195.48
REST OF LOUISIANA (LA)	$360.78	$188.74
METROPOLITAN BOSTON (MA)	$444.80	$212.69
REST OF MASSACHUSETTS (MA)	$403.63	$198.93
BALTIMORE/SURR. CNTYS (MD)	$416.34	$207.75
REST OF MARYLAND (MD)	$394.33	$197.60
SOUTHERN MAINE (ME)	$382.83	$190.18
REST OF MAINE (ME)	$364.18	$185.34
DETROIT (MI)	$394.03	$206.44
REST OF MICHIGAN (MI)	$370.99	$193.51
MINNESOTA (MN)	$387.02	$186.99
METROPOLITAN ST. LOUIS (MO)	$378.99	$193.92
METROPOLITAN KANSAS CITY (MO)	$375.17	$192.64
REST OF MISSOURI (MO)	$355.06	$187.50
MISSISSIPPI (MS)	$350.80	$183.43
MONTANA** (MT)	$391.42	$197.03
NORTH CAROLINA (NC)	$367.85	$186.48
NORTH DAKOTA** (ND)	$381.34	$186.95
NEBRASKA (NE)	$360.80	$181.38
NEW HAMPSHIRE (NH)	$400.01	$197.65
NORTHERN NJ (NJ)	$441.48	$215.98
REST OF NEW JERSEY (NJ)	$421.64	$209.36
NEW MEXICO (NM)	$373.26	$195.00
NEVADA** (NV)	$388.87	$194.29
MANHATTAN (NY)	$450.94	$225.05
NYC SUBURBS/LONG ISLAND (NY)	$462.59	$231.45
POUGHKPSIE/N NYC SUBURBS (NY)	$424.91	$212.05
QUEENS (NY)	$453.69	$223.92
REST OF NEW YORK (NY)	$373.37	$188.70
OHIO (OH)	$368.93	$191.45
OKLAHOMA (OK)	$359.78	$186.19
PORTLAND (OR)	$417.84	$201.87
REST OF OREGON (OR)	$385.36	$191.74
METROPOLITAN PHILADELPHIA (PA)	$407.48	$205.11
REST OF PENNSYLVANIA (PA)	$369.16	$190.71
PUERTO RICO (PR)	$394.07	$197.54
RHODE ISLAND (RI)	$400.38	$199.57
SOUTH CAROLINA (SC)	$369.10	$189.48
SOUTH DAKOTA** (SD)	$380.15	$185.75
TENNESSEE (TN)	$359.86	$183.16
BRAZORIA (TX)	$386.28	$193.63
DALLAS (TX)	$389.02	$195.41
GALVESTON (TX)	$387.62	$194.58
HOUSTON (TX)	$396.95	$203.92
BEAUMONT (TX)	$366.80	$189.90
FORT WORTH (TX)	$386.64	$194.97
AUSTIN (TX)	$404.85	$199.19
REST OF TEXAS (TX)	$376.52	$192.04
UTAH (UT)	$374.09	$191.36
VIRGINIA (VA)	$382.02	$190.93
VIRGIN ISLANDS (VI)	$394.07	$197.54
VERMONT (VT)	$380.44	$187.99
SEATTLE (KING CNTY) (WA)	$453.18	$214.66
REST OF WASHINGTON (WA)	$402.68	$197.98
WISCONSIN (WI)	$368.73	$182.50
WEST VIRGINIA (WV)	$364.67	$195.74
WYOMING** (WY)	$387.03	$192.64

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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 the 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 performed, reflecting local cost differences. The adjusted RVUs are summed and multiplied by the annual national conversion factor to produce the allowed amount. Non-facility and facility amounts differ primarily in the practice-expense RVU, since overhead costs assumed by the physician's own office versus a hospital or ambulatory surgical center differ.

RVUs — work 3.41, practice expense 7.8 (non-facility) / 1.98 (facility), malpractice 0.51 — × the locality GPCIs × the 2026 conversion factor of $33.40.

Good to know

This figure is an estimate only, not a guarantee of payment.
Medicare typically pays 80% of the allowed amount after the patient meets the annual Part B deductible; the patient or secondary payer is responsible for the remainder.
Modifiers, multiple-procedure reductions, bilateral rules, and other claim-level adjustments can change the final paid amount.
Sequestration and annual budget-neutrality adjustments may reduce the amount actually disbursed.
Local Medicare Administrative Contractor (MAC) policies, locality-specific GPCIs, and coverage determinations can affect payment; always verify with your MAC before billing.

Frequently asked

Why is the non-facility amount higher than the facility amount for this code?

In the non-facility setting, the physician's practice absorbs overhead costs (staff, supplies, equipment), so the practice-expense RVU—and therefore the total allowed amount—is higher. In a facility setting, the facility bills separately for overhead, so the physician's practice-expense RVU and the allowed amount are lower.

Does this amount reflect what Medicare actually pays?

No. This is the allowed amount under the fee schedule. Medicare generally reimburses 80% of this amount after the deductible is met, and the actual payment may be reduced further by sequestration, modifiers, or claim-specific adjustments.

Why might the amount differ in my locality?

The national amount is adjusted by Geographic Practice Cost Indices (GPCIs) that reflect regional variations in physician work, practice expense, and malpractice costs. Localities with higher costs of practice typically have higher adjusted amounts, and vice versa.

Where can I find the official descriptor for CPT 12054?

CPT code descriptors are copyrighted by the American Medical Association (AMA). Refer to your licensed CPT codebook or AMA resources for the official language.

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.