Medicare Reimbursement for CPT 12055

CPT 12055 is a physician procedure code reported under the Medicare Physician Fee Schedule (PFS). This page shows the estimated Medicare-allowed amount for this code nationally and by locality, broken out by non-facility (e.g., office) and facility (e.g., hospital) settings.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$545.77	$294.26
ALASKA* (AK)	$629.92	$362.07
ALABAMA (AL)	$486.80	$266.73
ARKANSAS (AR)	$479.38	$263.33
ARIZONA (AZ)	$530.08	$286.36
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$694.40	$339.77
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$707.60	$344.93
OXNARD-THOUSAND OAKS-VENTURA (CA)	$606.09	$308.81
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$609.57	$312.04
NAPA (CA)	$658.13	$326.64
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$695.40	$340.77
VALLEJO (CA)	$656.69	$325.20
BAKERSFIELD (CA)	$572.56	$296.91
CHICO (CA)	$570.12	$294.47
FRESNO (CA)	$570.12	$294.47
HANFORD-CORCORAN (CA)	$570.12	$294.47
MADERA (CA)	$570.12	$294.47
MERCED (CA)	$570.12	$294.47
MODESTO (CA)	$570.12	$294.47
REDDING (CA)	$570.12	$294.47
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$579.59	$303.93
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$597.68	$305.18
SALINAS (CA)	$595.47	$303.97
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$711.69	$349.01
SANTA CRUZ-WATSONVILLE (CA)	$614.71	$309.12
SANTA ROSA-PETALUMA (CA)	$620.83	$311.98
STOCKTON (CA)	$570.12	$294.47
VISALIA (CA)	$570.12	$294.47
YUBA CITY (CA)	$570.12	$294.47
EL CENTRO (CA)	$570.27	$294.61
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$609.18	$308.37
SAN LUIS OBISPO-PASO ROBLES (CA)	$586.02	$299.55
SANTA MARIA-SANTA BARBARA (CA)	$597.62	$304.36
REST OF CALIFORNIA (CA)	$570.12	$294.47
COLORADO (CO)	$564.76	$297.15
CONNECTICUT (CT)	$583.35	$312.47
DC + MD/VA SUBURBS (DC)	$622.83	$326.55
DELAWARE (DE)	$539.10	$290.61
FORT LAUDERDALE (FL)	$574.33	$319.55
MIAMI (FL)	$605.87	$344.05
REST OF FLORIDA (FL)	$544.29	$303.84
ATLANTA (GA)	$558.03	$302.50
REST OF GEORGIA (GA)	$511.48	$287.14
HAWAII, GUAM (HI)	$584.05	$298.09
IOWA (IA)	$496.62	$266.49
IDAHO (ID)	$500.70	$269.31
EAST ST. LOUIS (IL)	$546.00	$314.61
SUBURBAN CHICAGO (IL)	$579.47	$321.17
CHICAGO (IL)	$586.71	$333.94
REST OF ILLINOIS (IL)	$530.15	$300.52
INDIANA (IN)	$503.67	$270.52
KANSAS (KS)	$495.70	$268.33
KENTUCKY (KY)	$502.23	$278.64
NEW ORLEANS (LA)	$527.95	$291.28
REST OF LOUISIANA (LA)	$502.02	$279.43
METROPOLITAN BOSTON (MA)	$620.28	$319.98
REST OF MASSACHUSETTS (MA)	$561.75	$296.91
BALTIMORE/SURR. CNTYS (MD)	$582.07	$312.21
REST OF MARYLAND (MD)	$549.26	$294.74
SOUTHERN MAINE (ME)	$531.60	$282.35
REST OF MAINE (ME)	$505.08	$273.69
DETROIT (MI)	$552.99	$310.29
REST OF MICHIGAN (MI)	$517.39	$287.77
MINNESOTA (MN)	$535.80	$277.00
METROPOLITAN ST. LOUIS (MO)	$528.08	$288.65
METROPOLITAN KANSAS CITY (MO)	$522.54	$286.37
REST OF MISSOURI (MO)	$493.98	$277.18
MISSISSIPPI (MS)	$486.70	$270.16
MONTANA** (MT)	$545.71	$294.20
NORTH CAROLINA (NC)	$510.39	$275.73
NORTH DAKOTA** (ND)	$528.31	$276.80
NEBRASKA (NE)	$499.02	$266.88
NEW HAMPSHIRE (NH)	$557.26	$295.44
NORTHERN NJ (NJ)	$616.17	$324.42
REST OF NEW JERSEY (NJ)	$588.50	$313.86
NEW MEXICO (NM)	$520.99	$290.36
NEVADA** (NV)	$541.23	$289.47
MANHATTAN (NY)	$632.28	$340.03
NYC SUBURBS/LONG ISLAND (NY)	$650.23	$351.18
POUGHKPSIE/N NYC SUBURBS (NY)	$593.67	$318.27
QUEENS (NY)	$635.44	$338.16
REST OF NEW YORK (NY)	$518.55	$279.62
OHIO (OH)	$513.84	$284.21
OKLAHOMA (OK)	$499.65	$275.06
PORTLAND (OR)	$581.63	$302.21
REST OF OREGON (OR)	$535.56	$285.06
METROPOLITAN PHILADELPHIA (PA)	$569.24	$307.42
REST OF PENNSYLVANIA (PA)	$513.83	$282.95
PUERTO RICO (PR)	$549.40	$295.12
RHODE ISLAND (RI)	$557.58	$297.78
SOUTH CAROLINA (SC)	$513.26	$280.87
SOUTH DAKOTA** (SD)	$526.25	$274.75
TENNESSEE (TN)	$498.51	$269.89
BRAZORIA (TX)	$537.15	$287.90
DALLAS (TX)	$541.44	$290.93
GALVESTON (TX)	$539.30	$289.55
HOUSTON (TX)	$555.41	$305.66
BEAUMONT (TX)	$510.41	$281.53
FORT WORTH (TX)	$538.12	$290.13
AUSTIN (TX)	$564.16	$298.06
REST OF TEXAS (TX)	$524.06	$285.38
UTAH (UT)	$520.59	$284.17
VIRGINIA (VA)	$530.84	$283.61
VIRGIN ISLANDS (VI)	$549.40	$295.12
VERMONT (VT)	$527.55	$278.56
SEATTLE (KING CNTY) (WA)	$631.66	$323.05
REST OF WASHINGTON (WA)	$560.25	$295.41
WISCONSIN (WI)	$509.90	$268.96
WEST VIRGINIA (WV)	$510.00	$291.44
WYOMING** (WY)	$538.13	$286.62

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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 pricing for this code starts with three Relative Value Units (RVUs): physician work, practice expense, and malpractice. Each RVU component is adjusted by the Geographic Practice Cost Index (GPCI) values for the specific 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 rates differ mainly because practice-expense RVUs are lower in facility settings, where the facility — not the physician — bears many overhead costs.

RVUs — work 4.39, practice expense 11.07 (non-facility) / 3.54 (facility), malpractice 0.88 — × the locality GPCIs × the 2026 conversion factor of $33.40.

Good to know

This amount is an estimate only, not a guarantee of payment.
Medicare typically pays 80% of the allowed amount after the patient meets their deductible; the beneficiary or secondary insurance covers the remainder.
Modifiers, multiple-procedure reductions, sequestration, and annual budget-neutrality adjustments can change the final paid amount.
Local Medicare Administrative Contractor (MAC) policies and coverage determinations may affect whether and how this code is paid.
Always verify current rates and policies with your MAC before billing or making financial decisions.

Frequently asked

Why does the amount differ between non-facility and facility settings?

Practice-expense RVUs are higher in non-facility settings because the billing provider covers overhead costs like staff, supplies, and equipment. In facility settings, the facility absorbs many of these costs, so the practice-expense component — and the total allowed amount — is lower.

Why does the Medicare rate vary by locality for the same code?

Each locality has its own Geographic Practice Cost Index (GPCI) values, which adjust the work, practice-expense, and malpractice RVUs to reflect regional differences in wages, rent, and other costs.

Does this page show what the patient or secondary payer owes?

No. This page reflects the Medicare-allowed amount. Medicare generally pays 80% of that amount after the deductible is met, with the remaining portion potentially owed by the patient or a secondary payer.

Will this exact amount appear on my remittance advice?

Not necessarily. Modifiers, sequestration, annual budget-neutrality adjustments, and claim-specific factors can cause the actual paid amount to differ from this 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.