Medicare Reimbursement for CPT 21256

CPT 21256 is a surgical procedure code; because its official descriptor is licensed by the AMA, this page refers to it generically as 'this procedure code.' The page shows the Medicare Physician Fee Schedule (PFS) estimated allowed amount nationally and reflects how facility versus non-facility settings are handled under the fee schedule.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$1114.92	$1114.92
ALASKA* (AK)	$1382.82	$1382.82
ALABAMA (AL)	$1014.53	$1014.53
ARKANSAS (AR)	$1002.16	$1002.16
ARIZONA (AZ)	$1086.15	$1086.15
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$1285.91	$1285.91
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$1305.42	$1305.42
OXNARD-THOUSAND OAKS-VENTURA (CA)	$1169.70	$1169.70
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$1181.98	$1181.98
NAPA (CA)	$1236.50	$1236.50
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$1289.54	$1289.54
VALLEJO (CA)	$1231.28	$1231.28
BAKERSFIELD (CA)	$1125.78	$1125.78
CHICO (CA)	$1116.85	$1116.85
FRESNO (CA)	$1116.85	$1116.85
HANFORD-CORCORAN (CA)	$1116.85	$1116.85
MADERA (CA)	$1116.85	$1116.85
MERCED (CA)	$1116.85	$1116.85
MODESTO (CA)	$1116.85	$1116.85
REDDING (CA)	$1116.85	$1116.85
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$1151.20	$1151.20
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$1156.80	$1156.80
SALINAS (CA)	$1152.19	$1152.19
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$1320.23	$1320.23
SANTA CRUZ-WATSONVILLE (CA)	$1170.70	$1170.70
SANTA ROSA-PETALUMA (CA)	$1181.51	$1181.51
STOCKTON (CA)	$1116.85	$1116.85
VISALIA (CA)	$1116.85	$1116.85
YUBA CITY (CA)	$1116.85	$1116.85
EL CENTRO (CA)	$1117.38	$1117.38
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$1168.29	$1168.29
SAN LUIS OBISPO-PASO ROBLES (CA)	$1135.48	$1135.48
SANTA MARIA-SANTA BARBARA (CA)	$1153.50	$1153.50
REST OF CALIFORNIA (CA)	$1116.85	$1116.85
COLORADO (CO)	$1126.22	$1126.22
CONNECTICUT (CT)	$1182.16	$1182.16
DC + MD/VA SUBURBS (DC)	$1235.13	$1235.13
DELAWARE (DE)	$1101.84	$1101.84
FORT LAUDERDALE (FL)	$1206.65	$1206.65
MIAMI (FL)	$1295.60	$1295.60
REST OF FLORIDA (FL)	$1149.45	$1149.45
ATLANTA (GA)	$1145.00	$1145.00
REST OF GEORGIA (GA)	$1088.59	$1088.59
HAWAII, GUAM (HI)	$1129.41	$1129.41
IOWA (IA)	$1013.85	$1013.85
IDAHO (ID)	$1024.11	$1024.11
EAST ST. LOUIS (IL)	$1188.31	$1188.31
SUBURBAN CHICAGO (IL)	$1212.90	$1212.90
CHICAGO (IL)	$1259.10	$1259.10
REST OF ILLINOIS (IL)	$1137.22	$1137.22
INDIANA (IN)	$1028.53	$1028.53
KANSAS (KS)	$1020.49	$1020.49
KENTUCKY (KY)	$1057.78	$1057.78
NEW ORLEANS (LA)	$1103.85	$1103.85
REST OF LOUISIANA (LA)	$1060.63	$1060.63
METROPOLITAN BOSTON (MA)	$1210.83	$1210.83
REST OF MASSACHUSETTS (MA)	$1125.46	$1125.46
BALTIMORE/SURR. CNTYS (MD)	$1181.00	$1181.00
REST OF MARYLAND (MD)	$1117.14	$1117.14
SOUTHERN MAINE (ME)	$1071.71	$1071.71
REST OF MAINE (ME)	$1039.99	$1039.99
DETROIT (MI)	$1172.85	$1172.85
REST OF MICHIGAN (MI)	$1090.98	$1090.98
MINNESOTA (MN)	$1052.47	$1052.47
METROPOLITAN ST. LOUIS (MO)	$1094.34	$1094.34
METROPOLITAN KANSAS CITY (MO)	$1086.05	$1086.05
REST OF MISSOURI (MO)	$1052.37	$1052.37
MISSISSIPPI (MS)	$1026.90	$1026.90
MONTANA** (MT)	$1114.71	$1114.71
NORTH CAROLINA (NC)	$1047.43	$1047.43
NORTH DAKOTA** (ND)	$1051.63	$1051.63
NEBRASKA (NE)	$1015.29	$1015.29
NEW HAMPSHIRE (NH)	$1119.37	$1119.37
NORTHERN NJ (NJ)	$1227.72	$1227.72
REST OF NEW JERSEY (NJ)	$1188.12	$1188.12
NEW MEXICO (NM)	$1100.38	$1100.38
NEVADA** (NV)	$1097.56	$1097.56
MANHATTAN (NY)	$1284.35	$1284.35
NYC SUBURBS/LONG ISLAND (NY)	$1324.92	$1324.92
POUGHKPSIE/N NYC SUBURBS (NY)	$1204.33	$1204.33
QUEENS (NY)	$1277.67	$1277.67
REST OF NEW YORK (NY)	$1061.62	$1061.62
OHIO (OH)	$1078.09	$1078.09
OKLAHOMA (OK)	$1044.81	$1044.81
PORTLAND (OR)	$1144.93	$1144.93
REST OF OREGON (OR)	$1081.54	$1081.54
METROPOLITAN PHILADELPHIA (PA)	$1163.60	$1163.60
REST OF PENNSYLVANIA (PA)	$1073.54	$1073.54
PUERTO RICO (PR)	$1118.09	$1118.09
RHODE ISLAND (RI)	$1128.64	$1128.64
SOUTH CAROLINA (SC)	$1066.02	$1066.02
SOUTH DAKOTA** (SD)	$1044.17	$1044.17
TENNESSEE (TN)	$1026.17	$1026.17
BRAZORIA (TX)	$1092.18	$1092.18
DALLAS (TX)	$1103.24	$1103.24
GALVESTON (TX)	$1098.16	$1098.16
HOUSTON (TX)	$1156.55	$1156.55
BEAUMONT (TX)	$1068.37	$1068.37
FORT WORTH (TX)	$1100.29	$1100.29
AUSTIN (TX)	$1129.05	$1129.05
REST OF TEXAS (TX)	$1082.49	$1082.49
UTAH (UT)	$1078.06	$1078.06
VIRGINIA (VA)	$1076.23	$1076.23
VIRGIN ISLANDS (VI)	$1118.09	$1118.09
VERMONT (VT)	$1057.95	$1057.95
SEATTLE (KING CNTY) (WA)	$1222.52	$1222.52
REST OF WASHINGTON (WA)	$1119.89	$1119.89
WISCONSIN (WI)	$1023.00	$1023.00
WEST VIRGINIA (WV)	$1104.09	$1104.09
WYOMING** (WY)	$1087.22	$1087.22

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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's PFS amount is built from three Relative Value Units (RVUs) — physician work, practice expense, and malpractice — which are each adjusted by the Geographic Practice Cost Indices (GPCIs) for a given locality to account for local cost differences. The locality-adjusted RVUs are summed and multiplied by the annual Medicare conversion factor to produce the allowed amount. Non-facility (e.g., office) and facility (e.g., hospital) settings typically use different practice-expense RVUs because overhead costs differ, though for some codes — including this one — the practice-expense RVU is the same in both settings, so the estimated amounts align. The resulting figure is the Medicare-allowed amount before patient cost-sharing is applied.

RVUs — work 17.22, practice expense 12.97 (non-facility) / 12.97 (facility), malpractice 3.19 — × the locality GPCIs × the 2026 conversion factor of $33.40.

Good to know

This is an estimate only, based on national RVUs and the standard conversion factor — actual payment depends on your specific Medicare Administrative Contractor (MAC) and locality GPCIs.
Medicare typically pays 80% of the allowed amount after the patient meets their annual Part B deductible; the patient or secondary payer is responsible for the remainder.
Modifiers (e.g., bilateral, multiple procedure, assistant surgeon), sequestration reductions, and annual budget-neutrality adjustments can all change the final paid amount.
Always verify current rates and coverage rules directly with your MAC before billing or appealing a claim.

Frequently asked

Why does this page not show the CPT code's description?

CPT code descriptors are copyrighted and licensed by the American Medical Association (AMA), so this page refers to the code generically rather than reproducing the official text.

Why might the amount differ between facility and non-facility settings?

The practice-expense RVU component can differ by setting because non-facility settings (like a physician's office) often bear more overhead costs than facility settings (like a hospital). For some codes, including this one, that component is the same in both settings, so the estimated amounts are equal.

Does this amount reflect what Medicare will actually pay?

No — it's an estimate based on national RVUs and the standard conversion factor. Actual payment varies by locality, applicable modifiers, sequestration, and other adjustments determined by your MAC.

Why might this amount change year to year?

Medicare recalculates RVUs and the conversion factor annually, and may apply budget-neutrality adjustments, so fee schedule amounts can shift even if the code itself doesn't change.

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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.