Medicare Reimbursement for CPT 21255
CPT 21255 is a physician procedure code; the specific clinical description is omitted here because CPT descriptors are licensed by the AMA. This page shows the Medicare Physician Fee Schedule (PFS) estimated allowed amount for this code, both nationally and adjusted for your locality, and separately for non-facility and facility settings.
Medicare allowed amount (2026)
| Locality | Non-facility | Facility |
|---|---|---|
| National (unadjusted) | $1221.14 | $1221.14 |
| ALASKA* (AK) | $1517.23 | $1517.23 |
| ALABAMA (AL) | $1116.71 | $1116.71 |
| ARKANSAS (AR) | $1103.74 | $1103.74 |
| ARIZONA (AZ) | $1192.07 | $1192.07 |
| SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA) | $1446.55 | $1446.55 |
| SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA) | $1470.18 | $1470.18 |
| OXNARD-THOUSAND OAKS-VENTURA (CA) | $1302.06 | $1302.06 |
| LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA) | $1313.99 | $1313.99 |
| NAPA (CA) | $1385.54 | $1385.54 |
| SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA) | $1449.52 | $1449.52 |
| VALLEJO (CA) | $1381.26 | $1381.26 |
| BAKERSFIELD (CA) | $1249.62 | $1249.62 |
| CHICO (CA) | $1242.05 | $1242.05 |
| FRESNO (CA) | $1242.05 | $1242.05 |
| HANFORD-CORCORAN (CA) | $1242.05 | $1242.05 |
| MADERA (CA) | $1242.05 | $1242.05 |
| MERCED (CA) | $1242.05 | $1242.05 |
| MODESTO (CA) | $1242.05 | $1242.05 |
| REDDING (CA) | $1242.05 | $1242.05 |
| RIVERSIDE-SAN BERNARDINO-ONTARIO (CA) | $1270.29 | $1270.29 |
| SACRAMENTO-ROSEVILLE-FOLSOM (CA) | $1289.17 | $1289.17 |
| SALINAS (CA) | $1284.03 | $1284.03 |
| SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA) | $1482.29 | $1482.29 |
| SANTA CRUZ-WATSONVILLE (CA) | $1307.85 | $1307.85 |
| SANTA ROSA-PETALUMA (CA) | $1320.19 | $1320.19 |
| STOCKTON (CA) | $1242.05 | $1242.05 |
| VISALIA (CA) | $1242.05 | $1242.05 |
| YUBA CITY (CA) | $1242.05 | $1242.05 |
| EL CENTRO (CA) | $1242.49 | $1242.49 |
| SAN DIEGO-CHULA VISTA-CARLSBAD (CA) | $1303.66 | $1303.66 |
| SAN LUIS OBISPO-PASO ROBLES (CA) | $1264.96 | $1264.96 |
| SANTA MARIA-SANTA BARBARA (CA) | $1285.96 | $1285.96 |
| REST OF CALIFORNIA (CA) | $1242.05 | $1242.05 |
| COLORADO (CO) | $1243.36 | $1243.36 |
| CONNECTICUT (CT) | $1292.49 | $1292.49 |
| DC + MD/VA SUBURBS (DC) | $1358.28 | $1358.28 |
| DELAWARE (DE) | $1208.95 | $1208.95 |
| FORT LAUDERDALE (FL) | $1298.50 | $1298.50 |
| MIAMI (FL) | $1376.27 | $1376.27 |
| REST OF FLORIDA (FL) | $1241.55 | $1241.55 |
| ATLANTA (GA) | $1248.99 | $1248.99 |
| REST OF GEORGIA (GA) | $1180.34 | $1180.34 |
| HAWAII, GUAM (HI) | $1257.42 | $1257.42 |
| IOWA (IA) | $1123.29 | $1123.29 |
| IDAHO (ID) | $1132.58 | $1132.58 |
| EAST ST. LOUIS (IL) | $1266.91 | $1266.91 |
| SUBURBAN CHICAGO (IL) | $1307.03 | $1307.03 |
| CHICAGO (IL) | $1340.90 | $1340.90 |
| REST OF ILLINOIS (IL) | $1223.87 | $1223.87 |
| INDIANA (IN) | $1137.44 | $1137.44 |
| KANSAS (KS) | $1126.75 | $1126.75 |
| KENTUCKY (KY) | $1154.59 | $1154.59 |
| NEW ORLEANS (LA) | $1201.56 | $1201.56 |
| REST OF LOUISIANA (LA) | $1156.21 | $1156.21 |
| METROPOLITAN BOSTON (MA) | $1339.55 | $1339.55 |
| REST OF MASSACHUSETTS (MA) | $1241.30 | $1241.30 |
| BALTIMORE/SURR. CNTYS (MD) | $1290.31 | $1290.31 |
| REST OF MARYLAND (MD) | $1226.39 | $1226.39 |
| SOUTHERN MAINE (ME) | $1184.17 | $1184.17 |
| REST OF MAINE (ME) | $1145.56 | $1145.56 |
| DETROIT (MI) | $1262.29 | $1262.29 |
| REST OF MICHIGAN (MI) | $1186.03 | $1186.03 |
| MINNESOTA (MN) | $1175.21 | $1175.21 |
| METROPOLITAN ST. LOUIS (MO) | $1195.74 | $1195.74 |
| METROPOLITAN KANSAS CITY (MO) | $1186.63 | $1186.63 |
| REST OF MISSOURI (MO) | $1145.35 | $1145.35 |
| MISSISSIPPI (MS) | $1124.33 | $1124.33 |
| MONTANA** (MT) | $1220.96 | $1220.96 |
| NORTH CAROLINA (NC) | $1153.97 | $1153.97 |
| NORTH DAKOTA** (ND) | $1169.35 | $1169.35 |
| NEBRASKA (NE) | $1125.89 | $1125.89 |
| NEW HAMPSHIRE (NH) | $1232.08 | $1232.08 |
| NORTHERN NJ (NJ) | $1350.18 | $1350.18 |
| REST OF NEW JERSEY (NJ) | $1302.65 | $1302.65 |
| NEW MEXICO (NM) | $1194.44 | $1194.44 |
| NEVADA** (NV) | $1207.11 | $1207.11 |
| MANHATTAN (NY) | $1397.00 | $1397.00 |
| NYC SUBURBS/LONG ISLAND (NY) | $1435.01 | $1435.01 |
| POUGHKPSIE/N NYC SUBURBS (NY) | $1317.11 | $1317.11 |
| QUEENS (NY) | $1395.11 | $1395.11 |
| REST OF NEW YORK (NY) | $1168.61 | $1168.61 |
| OHIO (OH) | $1175.49 | $1175.49 |
| OKLAHOMA (OK) | $1144.69 | $1144.69 |
| PORTLAND (OR) | $1267.57 | $1267.57 |
| REST OF OREGON (OR) | $1193.11 | $1193.11 |
| METROPOLITAN PHILADELPHIA (PA) | $1270.63 | $1270.63 |
| REST OF PENNSYLVANIA (PA) | $1172.66 | $1172.66 |
| PUERTO RICO (PR) | $1225.69 | $1225.69 |
| RHODE ISLAND (RI) | $1240.73 | $1240.73 |
| SOUTH CAROLINA (SC) | $1167.57 | $1167.57 |
| SOUTH DAKOTA** (SD) | $1163.25 | $1163.25 |
| TENNESSEE (TN) | $1132.29 | $1132.29 |
| BRAZORIA (TX) | $1201.97 | $1201.97 |
| DALLAS (TX) | $1212.04 | $1212.04 |
| GALVESTON (TX) | $1207.22 | $1207.22 |
| HOUSTON (TX) | $1255.00 | $1255.00 |
| BEAUMONT (TX) | $1167.00 | $1167.00 |
| FORT WORTH (TX) | $1207.84 | $1207.84 |
| AUSTIN (TX) | $1243.30 | $1243.30 |
| REST OF TEXAS (TX) | $1185.51 | $1185.51 |
| UTAH (UT) | $1180.28 | $1180.28 |
| VIRGINIA (VA) | $1186.45 | $1186.45 |
| VIRGIN ISLANDS (VI) | $1225.69 | $1225.69 |
| VERMONT (VT) | $1172.74 | $1172.74 |
| SEATTLE (KING CNTY) (WA) | $1356.18 | $1356.18 |
| REST OF WASHINGTON (WA) | $1236.35 | $1236.35 |
| WISCONSIN (WI) | $1138.44 | $1138.44 |
| WEST VIRGINIA (WV) | $1188.92 | $1188.92 |
| WYOMING** (WY) | $1198.47 | $1198.47 |
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 by Geographic Practice Cost Indices (GPCIs) specific to the locality where the service is performed, reflecting local cost-of-living and practice cost differences. The adjusted RVUs are summed and multiplied by the annual Medicare conversion factor to produce the allowed amount. Non-facility and facility settings can have different practice-expense RVUs because overhead costs differ when the service is performed in a physician office versus a hospital or other facility.
RVUs — work 18, practice expense 15.95 (non-facility) / 15.95 (facility), malpractice 2.61 — × 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 insurer is responsible for the rest.
- Modifiers, multiple-procedure reductions, sequestration, and annual budget-neutrality adjustments can change the actual paid amount.
- Local Medicare Administrative Contractor (MAC) policies and coverage determinations may affect whether this code is reimbursable as billed.
- Always verify current-year figures and locality-specific amounts with your MAC before billing or appealing a denial.
Frequently asked
Why does the amount differ between non-facility and facility settings?
The practice-expense RVU component differs because overhead costs (staff, equipment, supplies) are typically higher when a service is performed in a physician's office compared to a hospital or facility setting where the facility itself bears some of those costs.
Why might my locality's amount differ from the national figure?
Geographic Practice Cost Indices (GPCIs) adjust the work, practice expense, and malpractice RVUs based on local wage, rent, and cost data, so the same code can have different allowed amounts in different regions.
Does this amount reflect what Medicare will actually pay?
No — it reflects the estimated PFS allowed amount. Actual payment depends on deductible status, the 80/20 coinsurance split, applicable modifiers, sequestration, and any claim-specific adjustments.
Can this fee amount be used to predict a denial outcome?
No. The fee schedule amount only indicates potential reimbursement if the service is covered and billed correctly; it does not determine medical necessity or coverage eligibility, which are assessed separately by the MAC.
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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