Medicare Reimbursement for CPT 21196

CPT 21196 is a surgical procedure code reported to Medicare and other payers; the full descriptor is not shown here because CPT codes are copyrighted by the AMA. This page shows the Medicare Physician Fee Schedule (PFS) estimated allowed amount for this code nationally and, where available, adjusted for your locality, broken out by non-facility and facility settings.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$1296.62	$1296.62
ALASKA* (AK)	$1625.35	$1625.35
ALABAMA (AL)	$1188.90	$1188.90
ARKANSAS (AR)	$1175.55	$1175.55
ARIZONA (AZ)	$1266.32	$1266.32
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$1517.50	$1517.50
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$1541.54	$1541.54
OXNARD-THOUSAND OAKS-VENTURA (CA)	$1373.06	$1373.06
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$1386.44	$1386.44
NAPA (CA)	$1456.15	$1456.15
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$1520.85	$1520.85
VALLEJO (CA)	$1451.32	$1451.32
BAKERSFIELD (CA)	$1320.88	$1320.88
CHICO (CA)	$1312.33	$1312.33
FRESNO (CA)	$1312.33	$1312.33
HANFORD-CORCORAN (CA)	$1312.33	$1312.33
MADERA (CA)	$1312.33	$1312.33
MERCED (CA)	$1312.33	$1312.33
MODESTO (CA)	$1312.33	$1312.33
REDDING (CA)	$1312.33	$1312.33
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$1344.24	$1344.24
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$1360.04	$1360.04
SALINAS (CA)	$1354.57	$1354.57
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$1555.24	$1555.24
SANTA CRUZ-WATSONVILLE (CA)	$1376.89	$1376.89
SANTA ROSA-PETALUMA (CA)	$1389.75	$1389.75
STOCKTON (CA)	$1312.33	$1312.33
VISALIA (CA)	$1312.33	$1312.33
YUBA CITY (CA)	$1312.33	$1312.33
EL CENTRO (CA)	$1312.82	$1312.82
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$1373.71	$1373.71
SAN LUIS OBISPO-PASO ROBLES (CA)	$1334.68	$1334.68
SANTA MARIA-SANTA BARBARA (CA)	$1356.17	$1356.17
REST OF CALIFORNIA (CA)	$1312.33	$1312.33
COLORADO (CO)	$1316.45	$1316.45
CONNECTICUT (CT)	$1370.90	$1370.90
DC + MD/VA SUBURBS (DC)	$1436.90	$1436.90
DELAWARE (DE)	$1283.83	$1283.83
FORT LAUDERDALE (FL)	$1382.99	$1382.99
MIAMI (FL)	$1468.59	$1468.59
REST OF FLORIDA (FL)	$1323.32	$1323.32
ATLANTA (GA)	$1326.78	$1326.78
REST OF GEORGIA (GA)	$1259.41	$1259.41
HAWAII, GUAM (HI)	$1326.34	$1326.34
IOWA (IA)	$1193.03	$1193.03
IDAHO (ID)	$1203.12	$1203.12
EAST ST. LOUIS (IL)	$1354.96	$1354.96
SUBURBAN CHICAGO (IL)	$1391.47	$1391.47
CHICAGO (IL)	$1431.57	$1431.57
REST OF ILLINOIS (IL)	$1306.88	$1306.88
INDIANA (IN)	$1208.04	$1208.04
KANSAS (KS)	$1197.86	$1197.86
KENTUCKY (KY)	$1230.56	$1230.56
NEW ORLEANS (LA)	$1279.36	$1279.36
REST OF LOUISIANA (LA)	$1232.72	$1232.72
METROPOLITAN BOSTON (MA)	$1414.42	$1414.42
REST OF MASSACHUSETTS (MA)	$1315.02	$1315.02
BALTIMORE/SURR. CNTYS (MD)	$1368.77	$1368.77
REST OF MARYLAND (MD)	$1301.56	$1301.56
SOUTHERN MAINE (ME)	$1255.59	$1255.59
REST OF MAINE (ME)	$1217.80	$1217.80
DETROIT (MI)	$1346.03	$1346.03
REST OF MICHIGAN (MI)	$1264.12	$1264.12
MINNESOTA (MN)	$1242.33	$1242.33
METROPOLITAN ST. LOUIS (MO)	$1271.87	$1271.87
METROPOLITAN KANSAS CITY (MO)	$1262.65	$1262.65
REST OF MISSOURI (MO)	$1222.34	$1222.34
MISSISSIPPI (MS)	$1198.67	$1198.67
MONTANA** (MT)	$1296.43	$1296.43
NORTH CAROLINA (NC)	$1226.23	$1226.23
NORTH DAKOTA** (ND)	$1238.09	$1238.09
NEBRASKA (NE)	$1195.32	$1195.32
NEW HAMPSHIRE (NH)	$1305.61	$1305.61
NORTHERN NJ (NJ)	$1429.22	$1429.22
REST OF NEW JERSEY (NJ)	$1381.13	$1381.13
NEW MEXICO (NM)	$1273.29	$1273.29
NEVADA** (NV)	$1280.69	$1280.69
MANHATTAN (NY)	$1481.97	$1481.97
NYC SUBURBS/LONG ISLAND (NY)	$1522.71	$1522.71
POUGHKPSIE/N NYC SUBURBS (NY)	$1397.21	$1397.21
QUEENS (NY)	$1478.18	$1478.18
REST OF NEW YORK (NY)	$1241.37	$1241.37
OHIO (OH)	$1252.20	$1252.20
OKLAHOMA (OK)	$1219.04	$1219.04
PORTLAND (OR)	$1339.94	$1339.94
REST OF OREGON (OR)	$1265.28	$1265.28
METROPOLITAN PHILADELPHIA (PA)	$1349.16	$1349.16
REST OF PENNSYLVANIA (PA)	$1248.59	$1248.59
PUERTO RICO (PR)	$1300.86	$1300.86
RHODE ISLAND (RI)	$1316.02	$1316.02
SOUTH CAROLINA (SC)	$1242.34	$1242.34
SOUTH DAKOTA** (SD)	$1231.20	$1231.20
TENNESSEE (TN)	$1203.71	$1203.71
BRAZORIA (TX)	$1275.70	$1275.70
DALLAS (TX)	$1286.66	$1286.66
GALVESTON (TX)	$1281.46	$1281.46
HOUSTON (TX)	$1335.46	$1335.46
BEAUMONT (TX)	$1242.85	$1242.85
FORT WORTH (TX)	$1282.74	$1282.74
AUSTIN (TX)	$1316.89	$1316.89
REST OF TEXAS (TX)	$1260.56	$1260.56
UTAH (UT)	$1255.39	$1255.39
VIRGINIA (VA)	$1258.82	$1258.82
VIRGIN ISLANDS (VI)	$1300.86	$1300.86
VERMONT (VT)	$1242.75	$1242.75
SEATTLE (KING CNTY) (WA)	$1430.49	$1430.49
REST OF WASHINGTON (WA)	$1309.44	$1309.44
WISCONSIN (WI)	$1206.61	$1206.61
WEST VIRGINIA (WV)	$1271.01	$1271.01
WYOMING** (WY)	$1271.00	$1271.00

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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 PFS amounts are built from three Relative Value Units (RVUs) — physician work, practice expense, and malpractice — assigned to each code. Each RVU component is adjusted by Geographic Practice Cost Indices (GPCIs) specific to the locality where the service is performed, then the adjusted RVUs are summed and multiplied by the annual Medicare conversion factor to produce a dollar amount. Practice-expense RVUs differ between non-facility (e.g., office) and facility (e.g., hospital) settings because overhead costs differ, which is why the two amounts can diverge. The conversion factor itself is updated annually by CMS and is subject to legislative and budget-neutrality adjustments.

RVUs — work 20.31, practice expense 15.56 (non-facility) / 15.56 (facility), malpractice 2.95 — × 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's deductible is met; the patient or secondary payer is responsible for the remainder.
Actual payment can vary by locality, facility type, modifiers, and claim-specific circumstances.
Annual conversion factor updates, sequestration, and budget-neutrality adjustments can change amounts year to year.
Always verify final allowed amounts with your Medicare Administrative Contractor (MAC) before billing or appealing a denial.

Frequently asked

Why does the facility amount differ from the non-facility amount?

The practice-expense RVU component is calculated differently depending on whether the service is performed in a non-facility setting (like a physician office) or a facility setting (like a hospital), because the overhead costs borne by the billing provider differ.

Does this amount reflect what my specific MAC will pay?

Not exactly. This is a national PFS estimate; your Medicare Administrative Contractor applies the GPCIs for your specific locality, which can raise or lower the final allowed amount.

Can modifiers change this amount?

Yes. Modifiers such as those indicating bilateral procedures, assistant surgeons, or reduced services can increase or decrease the allowed amount from the base PFS figure shown here.

Why can't you show the CPT code description?

CPT code descriptors are copyrighted by the American Medical Association (AMA) and cannot be reproduced here; refer to your CPT codebook or EHR system for the official descriptor.

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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.