Medicare Reimbursement for CPT Code 21242

CPT code 21242 is a procedure code billed to Medicare under the Physician Fee Schedule (PFS). This page shows the estimated Medicare allowed amount for this code nationally and by locality, with separate figures for non-facility and facility settings.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$923.20	$923.20
ALASKA* (AK)	$1154.60	$1154.60
ALABAMA (AL)	$845.95	$845.95
ARKANSAS (AR)	$836.38	$836.38
ARIZONA (AZ)	$901.54	$901.54
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$1084.22	$1084.22
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$1101.56	$1101.56
OXNARD-THOUSAND OAKS-VENTURA (CA)	$979.57	$979.57
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$988.94	$988.94
NAPA (CA)	$1039.85	$1039.85
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$1086.56	$1086.56
VALLEJO (CA)	$1036.47	$1036.47
BAKERSFIELD (CA)	$941.72	$941.72
CHICO (CA)	$935.75	$935.75
FRESNO (CA)	$935.75	$935.75
HANFORD-CORCORAN (CA)	$935.75	$935.75
MADERA (CA)	$935.75	$935.75
MERCED (CA)	$935.75	$935.75
MODESTO (CA)	$935.75	$935.75
REDDING (CA)	$935.75	$935.75
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$958.04	$958.04
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$970.18	$970.18
SALINAS (CA)	$966.29	$966.29
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$1111.12	$1111.12
SANTA CRUZ-WATSONVILLE (CA)	$982.76	$982.76
SANTA ROSA-PETALUMA (CA)	$991.97	$991.97
STOCKTON (CA)	$935.75	$935.75
VISALIA (CA)	$935.75	$935.75
YUBA CITY (CA)	$935.75	$935.75
EL CENTRO (CA)	$936.09	$936.09
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$980.25	$980.25
SAN LUIS OBISPO-PASO ROBLES (CA)	$952.05	$952.05
SANTA MARIA-SANTA BARBARA (CA)	$967.51	$967.51
REST OF CALIFORNIA (CA)	$935.75	$935.75
COLORADO (CO)	$938.10	$938.10
CONNECTICUT (CT)	$976.35	$976.35
DC + MD/VA SUBURBS (DC)	$1024.12	$1024.12
DELAWARE (DE)	$914.08	$914.08
FORT LAUDERDALE (FL)	$983.72	$983.72
MIAMI (FL)	$1043.95	$1043.95
REST OF FLORIDA (FL)	$941.13	$941.13
ATLANTA (GA)	$944.52	$944.52
REST OF GEORGIA (GA)	$895.47	$895.47
HAWAII, GUAM (HI)	$946.17	$946.17
IOWA (IA)	$849.49	$849.49
IDAHO (ID)	$856.61	$856.61
EAST ST. LOUIS (IL)	$962.64	$962.64
SUBURBAN CHICAGO (IL)	$989.88	$989.88
CHICAGO (IL)	$1017.53	$1017.53
REST OF ILLINOIS (IL)	$928.96	$928.96
INDIANA (IN)	$860.16	$860.16
KANSAS (KS)	$852.68	$852.68
KENTUCKY (KY)	$875.27	$875.27
NEW ORLEANS (LA)	$910.19	$910.19
REST OF LOUISIANA (LA)	$876.71	$876.71
METROPOLITAN BOSTON (MA)	$1008.66	$1008.66
REST OF MASSACHUSETTS (MA)	$936.93	$936.93
BALTIMORE/SURR. CNTYS (MD)	$974.79	$974.79
REST OF MARYLAND (MD)	$926.86	$926.86
SOUTHERN MAINE (ME)	$894.40	$894.40
REST OF MAINE (ME)	$866.86	$866.86
DETROIT (MI)	$957.13	$957.13
REST OF MICHIGAN (MI)	$899.10	$899.10
MINNESOTA (MN)	$885.76	$885.76
METROPOLITAN ST. LOUIS (MO)	$905.14	$905.14
METROPOLITAN KANSAS CITY (MO)	$898.49	$898.49
REST OF MISSOURI (MO)	$869.10	$869.10
MISSISSIPPI (MS)	$852.55	$852.55
MONTANA** (MT)	$923.06	$923.06
NORTH CAROLINA (NC)	$872.96	$872.96
NORTH DAKOTA** (ND)	$882.33	$882.33
NEBRASKA (NE)	$851.21	$851.21
NEW HAMPSHIRE (NH)	$930.14	$930.14
NORTHERN NJ (NJ)	$1018.48	$1018.48
REST OF NEW JERSEY (NJ)	$983.76	$983.76
NEW MEXICO (NM)	$905.57	$905.57
NEVADA** (NV)	$912.09	$912.09
MANHATTAN (NY)	$1055.35	$1055.35
NYC SUBURBS/LONG ISLAND (NY)	$1084.24	$1084.24
POUGHKPSIE/N NYC SUBURBS (NY)	$995.05	$995.05
QUEENS (NY)	$1053.03	$1053.03
REST OF NEW YORK (NY)	$883.81	$883.81
OHIO (OH)	$890.77	$890.77
OKLAHOMA (OK)	$867.29	$867.29
PORTLAND (OR)	$955.27	$955.27
REST OF OREGON (OR)	$901.25	$901.25
METROPOLITAN PHILADELPHIA (PA)	$960.58	$960.58
REST OF PENNSYLVANIA (PA)	$888.33	$888.33
PUERTO RICO (PR)	$926.34	$926.34
RHODE ISLAND (RI)	$937.31	$937.31
SOUTH CAROLINA (SC)	$884.07	$884.07
SOUTH DAKOTA** (SD)	$877.51	$877.51
TENNESSEE (TN)	$856.85	$856.85
BRAZORIA (TX)	$908.45	$908.45
DALLAS (TX)	$916.19	$916.19
GALVESTON (TX)	$912.51	$912.51
HOUSTON (TX)	$950.22	$950.22
BEAUMONT (TX)	$884.20	$884.20
FORT WORTH (TX)	$913.30	$913.30
AUSTIN (TX)	$938.30	$938.30
REST OF TEXAS (TX)	$897.19	$897.19
UTAH (UT)	$893.44	$893.44
VIRGINIA (VA)	$896.53	$896.53
VIRGIN ISLANDS (VI)	$926.34	$926.34
VERMONT (VT)	$885.42	$885.42
SEATTLE (KING CNTY) (WA)	$1020.43	$1020.43
REST OF WASHINGTON (WA)	$933.03	$933.03
WISCONSIN (WI)	$859.67	$859.67
WEST VIRGINIA (WV)	$903.19	$903.19
WYOMING** (WY)	$905.31	$905.31

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 — each adjusted by the Geographic Practice Cost Indices (GPCIs) specific to a given locality. These adjusted RVUs are summed and multiplied by the annual national conversion factor to produce a dollar amount. Practice-expense RVUs typically differ between non-facility (e.g., office) and facility (e.g., hospital) settings, since overhead costs differ, which is why the two amounts can diverge. The conversion factor is updated annually and applies uniformly across all codes before locality adjustments.

RVUs — work 14.23, practice expense 11.35 (non-facility) / 11.35 (facility), malpractice 2.06 — × 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 annual Part B deductible is met; the patient or secondary payer is responsible for the remainder.
Modifiers, multiple-procedure reductions, sequestration, and annual budget-neutrality adjustments can change the actual amount paid.
Locality-specific GPCIs mean the real amount can differ from the national figure shown here.
Always verify current rates and coverage rules with your Medicare Administrative Contractor (MAC) before billing.

Frequently asked

Why is the amount different in facility vs. non-facility settings?

Practice-expense RVUs differ because non-facility settings (like a physician's office) include overhead costs that are already reimbursed separately when performed in a facility setting, such as a hospital.

Does this amount reflect what Medicare will actually pay?

No. This is an estimated allowed amount derived from standard RVU and GPCI data. Actual payment depends on your specific locality, applicable modifiers, sequestration, and other adjustments.

Why can't you show the CPT code description here?

CPT code descriptors are licensed by the American Medical Association and cannot be reproduced without a license, so this page refers to the code generically.

How often do these amounts change?

The Medicare conversion factor and RVUs are typically updated annually, and GPCIs may be revised periodically, so amounts can change from year to year.

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.