Medicare Reimbursement for CPT 21086
CPT 21086 is a procedure code reported to Medicare for physician and outpatient billing purposes. This page shows the Medicare Physician Fee Schedule (PFS) allowed amount for the code, including national figures and how they differ by locality and by non-facility versus facility place of service.
Medicare allowed amount (2026)
| Locality | Non-facility | Facility |
|---|---|---|
| National (unadjusted) | $1627.29 | $1126.61 |
| ALASKA* (AK) | $2038.17 | $1504.94 |
| ALABAMA (AL) | $1496.68 | $1058.59 |
| ARKANSAS (AR) | $1480.38 | $1050.30 |
| ARIZONA (AZ) | $1591.55 | $1106.39 |
| SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA) | $1948.43 | $1242.47 |
| SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA) | $1981.20 | $1259.22 |
| OXNARD-THOUSAND OAKS-VENTURA (CA) | $1747.14 | $1155.34 |
| LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA) | $1762.18 | $1169.87 |
| NAPA (CA) | $1863.47 | $1203.58 |
| SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA) | $1951.57 | $1245.61 |
| VALLEJO (CA) | $1858.95 | $1199.06 |
| BAKERSFIELD (CA) | $1676.22 | $1127.48 |
| CHICO (CA) | $1667.87 | $1119.13 |
| FRESNO (CA) | $1667.87 | $1119.13 |
| HANFORD-CORCORAN (CA) | $1667.87 | $1119.13 |
| MADERA (CA) | $1667.87 | $1119.13 |
| MERCED (CA) | $1667.87 | $1119.13 |
| MODESTO (CA) | $1667.87 | $1119.13 |
| REDDING (CA) | $1667.87 | $1119.13 |
| RIVERSIDE-SAN BERNARDINO-ONTARIO (CA) | $1697.91 | $1149.16 |
| SACRAMENTO-ROSEVILLE-FOLSOM (CA) | $1731.83 | $1149.54 |
| SALINAS (CA) | $1724.88 | $1144.59 |
| SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA) | $1994.01 | $1272.03 |
| SANTA CRUZ-WATSONVILLE (CA) | $1757.37 | $1149.04 |
| SANTA ROSA-PETALUMA (CA) | $1774.08 | $1159.25 |
| STOCKTON (CA) | $1667.87 | $1119.13 |
| VISALIA (CA) | $1667.87 | $1119.13 |
| YUBA CITY (CA) | $1667.87 | $1119.13 |
| EL CENTRO (CA) | $1668.33 | $1119.59 |
| SAN DIEGO-CHULA VISTA-CARLSBAD (CA) | $1751.44 | $1152.63 |
| SAN LUIS OBISPO-PASO ROBLES (CA) | $1699.04 | $1128.77 |
| SANTA MARIA-SANTA BARBARA (CA) | $1727.52 | $1143.73 |
| REST OF CALIFORNIA (CA) | $1667.87 | $1119.13 |
| COLORADO (CO) | $1663.21 | $1130.49 |
| CONNECTICUT (CT) | $1718.67 | $1179.43 |
| DC + MD/VA SUBURBS (DC) | $1810.48 | $1220.68 |
| DELAWARE (DE) | $1613.33 | $1118.66 |
| FORT LAUDERDALE (FL) | $1711.20 | $1204.01 |
| MIAMI (FL) | $1797.96 | $1276.75 |
| REST OF FLORIDA (FL) | $1641.77 | $1163.12 |
| ATLANTA (GA) | $1659.85 | $1151.16 |
| REST OF GEORGIA (GA) | $1566.71 | $1120.11 |
| HAWAII, GUAM (HI) | $1687.78 | $1118.51 |
| IOWA (IA) | $1510.10 | $1051.97 |
| IDAHO (ID) | $1520.73 | $1060.10 |
| EAST ST. LOUIS (IL) | $1662.78 | $1202.16 |
| SUBURBAN CHICAGO (IL) | $1723.70 | $1209.50 |
| CHICAGO (IL) | $1755.97 | $1252.79 |
| REST OF ILLINOIS (IL) | $1616.14 | $1159.01 |
| INDIANA (IN) | $1527.00 | $1062.87 |
| KANSAS (KS) | $1511.99 | $1059.37 |
| KENTUCKY (KY) | $1539.00 | $1093.90 |
| NEW ORLEANS (LA) | $1597.07 | $1125.93 |
| REST OF LOUISIANA (LA) | $1540.07 | $1096.97 |
| METROPOLITAN BOSTON (MA) | $1790.98 | $1193.17 |
| REST OF MASSACHUSETTS (MA) | $1659.96 | $1132.74 |
| BALTIMORE/SURR. CNTYS (MD) | $1715.02 | $1177.79 |
| REST OF MARYLAND (MD) | $1636.53 | $1129.85 |
| SOUTHERN MAINE (ME) | $1586.75 | $1090.58 |
| REST OF MAINE (ME) | $1534.46 | $1073.84 |
| DETROIT (MI) | $1665.16 | $1182.01 |
| REST OF MICHIGAN (MI) | $1576.13 | $1119.01 |
| MINNESOTA (MN) | $1583.41 | $1068.21 |
| METROPOLITAN ST. LOUIS (MO) | $1592.69 | $1116.04 |
| METROPOLITAN KANSAS CITY (MO) | $1580.96 | $1110.82 |
| REST OF MISSOURI (MO) | $1524.87 | $1093.29 |
| MISSISSIPPI (MS) | $1502.48 | $1071.40 |
| MONTANA** (MT) | $1627.11 | $1126.43 |
| NORTH CAROLINA (NC) | $1545.45 | $1078.32 |
| NORTH DAKOTA** (ND) | $1572.53 | $1071.85 |
| NEBRASKA (NE) | $1514.14 | $1052.02 |
| NEW HAMPSHIRE (NH) | $1645.49 | $1124.28 |
| NORTHERN NJ (NJ) | $1800.58 | $1219.79 |
| REST OF NEW JERSEY (NJ) | $1735.33 | $1188.59 |
| NEW MEXICO (NM) | $1585.66 | $1126.54 |
| NEVADA** (NV) | $1612.62 | $1111.44 |
| MANHATTAN (NY) | $1850.59 | $1268.80 |
| NYC SUBURBS/LONG ISLAND (NY) | $1895.14 | $1299.83 |
| POUGHKPSIE/N NYC SUBURBS (NY) | $1751.97 | $1203.73 |
| QUEENS (NY) | $1851.81 | $1260.01 |
| REST OF NEW YORK (NY) | $1563.67 | $1088.03 |
| OHIO (OH) | $1564.97 | $1107.85 |
| OKLAHOMA (OK) | $1529.18 | $1082.07 |
| PORTLAND (OR) | $1697.11 | $1140.85 |
| REST OF OREGON (OR) | $1597.01 | $1098.34 |
| METROPOLITAN PHILADELPHIA (PA) | $1689.39 | $1168.18 |
| REST OF PENNSYLVANIA (PA) | $1562.79 | $1103.16 |
| PUERTO RICO (PR) | $1633.88 | $1127.69 |
| RHODE ISLAND (RI) | $1656.65 | $1139.45 |
| SOUTH CAROLINA (SC) | $1558.38 | $1095.75 |
| SOUTH DAKOTA** (SD) | $1566.08 | $1065.40 |
| TENNESSEE (TN) | $1518.65 | $1063.54 |
| BRAZORIA (TX) | $1606.97 | $1110.80 |
| DALLAS (TX) | $1618.59 | $1119.92 |
| GALVESTON (TX) | $1612.84 | $1115.67 |
| HOUSTON (TX) | $1663.36 | $1166.19 |
| BEAUMONT (TX) | $1555.51 | $1099.90 |
| FORT WORTH (TX) | $1612.55 | $1118.88 |
| AUSTIN (TX) | $1660.44 | $1130.72 |
| REST OF TEXAS (TX) | $1581.38 | $1106.24 |
| UTAH (UT) | $1574.40 | $1103.76 |
| VIRGINIA (VA) | $1587.87 | $1095.70 |
| VIRGIN ISLANDS (VI) | $1633.88 | $1127.69 |
| VERMONT (VT) | $1574.50 | $1078.83 |
| SEATTLE (KING CNTY) (WA) | $1815.47 | $1201.13 |
| REST OF WASHINGTON (WA) | $1654.21 | $1126.99 |
| WISCONSIN (WI) | $1533.06 | $1053.41 |
| WEST VIRGINIA (WV) | $1572.08 | $1136.99 |
| WYOMING** (WY) | $1603.32 | $1102.64 |
Look up another code or locality →
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) — physician work, practice expense, and malpractice — assigned to the code. Each RVU component is adjusted using 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 (e.g., office) and facility (e.g., hospital) settings use different practice-expense RVUs, which is why the same code can have two different allowed amounts depending on where it's performed.
RVUs — work 24.26, practice expense 21.7 (non-facility) / 6.71 (facility), malpractice 2.76 — × 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 patient meets their deductible; the remainder is patient or secondary-payer responsibility.
- Modifiers, sequestration, multiple-procedure reductions, and annual budget-neutrality adjustments can change the actual paid amount.
- Local Medicare Administrative Contractor (MAC) policies and coverage determinations may further affect payment.
- Figures shown are national averages; actual locality-specific amounts may differ based on GPCI values.
Frequently asked
Why does the facility amount differ from the non-facility amount?
Facility amounts use lower practice-expense RVUs because overhead costs (equipment, supplies, staff) are assumed to be borne by the facility rather than the billing physician's practice.
Will my actual payment match the national amount shown?
Not exactly — actual payment depends on your specific locality's GPCI adjustments, any applicable modifiers, and current-year adjustments like sequestration.
Does this page tell me if CPT 21086 is covered by Medicare?
No. This page only reflects the fee schedule allowed amount if the service is covered and payable; coverage and medical necessity determinations are separate from pricing.
What RVU components make up this fee?
The fee is derived from work RVUs, practice expense RVUs (which vary by setting), and malpractice RVUs, each adjusted by locality GPCIs and the conversion factor.
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.
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