Medicare Reimbursement for CPT 21011

CPT 21011 is a procedure code describing a specific medical or surgical service; the full plain-language descriptor is not reproduced here due to AMA licensing restrictions. This page shows the estimated Medicare Physician Fee Schedule (PFS) allowed amount for this code at the national level and adjusted for your 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)	$395.13	$250.17
ALASKA* (AK)	$454.14	$299.76
ALABAMA (AL)	$352.46	$225.62
ARKANSAS (AR)	$347.08	$222.56
ARIZONA (AZ)	$383.91	$243.44
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$508.98	$304.58
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$518.90	$309.87
OXNARD-THOUSAND OAKS-VENTURA (CA)	$442.13	$270.79
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$444.40	$272.92
NAPA (CA)	$481.58	$290.52
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$509.58	$305.19
VALLEJO (CA)	$480.71	$289.65
BAKERSFIELD (CA)	$416.93	$258.06
CHICO (CA)	$415.45	$256.57
FRESNO (CA)	$415.45	$256.57
HANFORD-CORCORAN (CA)	$415.45	$256.57
MADERA (CA)	$415.45	$256.57
MERCED (CA)	$415.45	$256.57
MODESTO (CA)	$415.45	$256.57
REDDING (CA)	$415.45	$256.57
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$421.16	$262.28
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$436.05	$267.47
SALINAS (CA)	$434.45	$266.44
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$521.36	$312.33
SANTA CRUZ-WATSONVILLE (CA)	$449.15	$273.02
SANTA ROSA-PETALUMA (CA)	$453.66	$275.65
STOCKTON (CA)	$415.45	$256.57
VISALIA (CA)	$415.45	$256.57
YUBA CITY (CA)	$415.45	$256.57
EL CENTRO (CA)	$415.54	$256.66
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$444.81	$271.44
SAN LUIS OBISPO-PASO ROBLES (CA)	$427.48	$262.37
SANTA MARIA-SANTA BARBARA (CA)	$436.11	$267.09
REST OF CALIFORNIA (CA)	$415.45	$256.57
COLORADO (CO)	$410.34	$256.10
CONNECTICUT (CT)	$422.35	$266.23
DC + MD/VA SUBURBS (DC)	$452.22	$281.46
DELAWARE (DE)	$390.47	$247.25
FORT LAUDERDALE (FL)	$413.07	$266.23
MIAMI (FL)	$433.68	$282.77
REST OF FLORIDA (FL)	$391.72	$253.14
ATLANTA (GA)	$403.46	$256.18
REST OF GEORGIA (GA)	$368.30	$239.00
HAWAII, GUAM (HI)	$426.03	$261.21
IOWA (IA)	$360.67	$228.03
IDAHO (ID)	$363.41	$230.05
EAST ST. LOUIS (IL)	$390.69	$257.33
SUBURBAN CHICAGO (IL)	$417.04	$268.17
CHICAGO (IL)	$420.14	$274.45
REST OF ILLINOIS (IL)	$380.75	$248.40
INDIANA (IN)	$365.60	$231.22
KANSAS (KS)	$359.48	$228.44
KENTUCKY (KY)	$362.56	$233.69
NEW ORLEANS (LA)	$381.03	$244.62
REST OF LOUISIANA (LA)	$362.20	$233.91
METROPOLITAN BOSTON (MA)	$451.48	$278.40
REST OF MASSACHUSETTS (MA)	$407.93	$255.29
BALTIMORE/SURR. CNTYS (MD)	$421.32	$265.78
REST OF MARYLAND (MD)	$398.02	$251.32
SOUTHERN MAINE (ME)	$386.08	$242.43
REST OF MAINE (ME)	$366.05	$232.69
DETROIT (MI)	$397.48	$257.59
REST OF MICHIGAN (MI)	$373.07	$240.72
MINNESOTA (MN)	$390.79	$241.62
METROPOLITAN ST. LOUIS (MO)	$381.73	$243.73
METROPOLITAN KANSAS CITY (MO)	$377.65	$241.53
REST OF MISSOURI (MO)	$356.05	$231.09
MISSISSIPPI (MS)	$351.61	$226.80
MONTANA** (MT)	$395.10	$250.14
NORTH CAROLINA (NC)	$369.99	$234.74
NORTH DAKOTA** (ND)	$384.62	$239.66
NEBRASKA (NE)	$362.57	$228.77
NEW HAMPSHIRE (NH)	$404.40	$253.49
NORTHERN NJ (NJ)	$447.26	$279.11
REST OF NEW JERSEY (NJ)	$426.50	$268.21
NEW MEXICO (NM)	$375.46	$242.53
NEVADA** (NV)	$392.46	$247.35
MANHATTAN (NY)	$457.09	$288.65
NYC SUBURBS/LONG ISLAND (NY)	$469.45	$297.09
POUGHKPSIE/N NYC SUBURBS (NY)	$429.83	$271.10
QUEENS (NY)	$460.14	$288.80
REST OF NEW YORK (NY)	$375.88	$238.17
OHIO (OH)	$370.92	$238.57
OKLAHOMA (OK)	$361.24	$231.79
PORTLAND (OR)	$423.23	$262.18
REST OF OREGON (OR)	$388.76	$244.38
METROPOLITAN PHILADELPHIA (PA)	$411.78	$260.88
REST OF PENNSYLVANIA (PA)	$371.21	$238.13
PUERTO RICO (PR)	$397.95	$251.39
RHODE ISLAND (RI)	$404.31	$254.57
SOUTH CAROLINA (SC)	$371.20	$237.26
SOUTH DAKOTA** (SD)	$383.38	$238.42
TENNESSEE (TN)	$361.47	$229.70
BRAZORIA (TX)	$389.50	$245.84
DALLAS (TX)	$392.38	$248.00
GALVESTON (TX)	$390.91	$246.96
HOUSTON (TX)	$400.61	$256.66
BEAUMONT (TX)	$368.68	$236.77
FORT WORTH (TX)	$389.81	$246.88
AUSTIN (TX)	$409.54	$256.18
REST OF TEXAS (TX)	$379.14	$241.57
UTAH (UT)	$376.53	$240.27
VIRGINIA (VA)	$385.17	$242.67
VIRGIN ISLANDS (VI)	$397.95	$251.39
VERMONT (VT)	$383.59	$240.08
SEATTLE (KING CNTY) (WA)	$460.31	$282.44
REST OF WASHINGTON (WA)	$407.00	$254.36
WISCONSIN (WI)	$371.13	$232.26
WEST VIRGINIA (WV)	$366.10	$240.13
WYOMING** (WY)	$390.53	$245.57

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Maximum units per day (MUE)

Medicare’s Medically Unlikely Edit caps this code at 4 units per patient per day — Date of Service Edit: Clinical. 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) — physician work, practice expense, and malpractice — assigned to the code. Each RVU component is adjusted by the Geographic Practice Cost Index (GPCI) for the specific locality to reflect local cost differences, then the adjusted RVUs are summed and multiplied by the annual national conversion factor to produce a dollar amount. Practice-expense RVUs differ between non-facility and facility settings because facilities (like hospitals) absorb certain overhead costs that independent practices otherwise bear, which typically makes the facility rate lower than the non-facility rate. The conversion factor is updated annually and can shift payment amounts even if RVUs stay the same.

RVUs — work 2.92, practice expense 8.38 (non-facility) / 4.04 (facility), malpractice 0.53 — × 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 approved amount after the annual Part B deductible is met; the patient or secondary insurer may be responsible for the rest.
Modifiers, multiple-procedure reductions, sequestration, and annual budget-neutrality adjustments can change the actual paid amount.
Rates vary by locality based on GPCI values; always confirm the specific locality used for a claim.
Verify current, claim-specific amounts with your Medicare Administrative Contractor (MAC) before billing or appealing a denial.

Frequently asked

Why is the facility rate lower than the non-facility rate for this code?

The facility rate uses a lower practice-expense RVU because the facility (such as a hospital) typically bears costs like equipment, supplies, and staff that a physician's own office would otherwise cover in the non-facility setting.

Why does the amount differ by locality?

Each locality has its own GPCI values for work, practice expense, and malpractice, reflecting local cost-of-living and practice-cost differences, which adjust the base RVUs before the conversion factor is applied.

Does this amount reflect what the patient will owe?

No. This figure is the Medicare-approved amount before cost-sharing; Medicare generally pays 80% after the deductible, and the patient or secondary payer is typically responsible for the remainder.

Will this amount change during the year?

It can. CMS applies annual updates to the conversion factor and RVUs, and mid-year adjustments such as sequestration or budget-neutrality corrections can also affect the final paid amount.

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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.