Medicare Reimbursement for CPT 21261

This page covers the Medicare Physician Fee Schedule (PFS) allowed amount for this procedure code (CPT descriptors are proprietary to the AMA and not reproduced here). It shows both the national average payment and how the amount can shift by locality, as well as the non-facility versus facility rates.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$2175.73	$2175.73
ALASKA* (AK)	$2693.90	$2693.90
ALABAMA (AL)	$1978.79	$1978.79
ARKANSAS (AR)	$1954.51	$1954.51
ARIZONA (AZ)	$2119.40	$2119.40
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$2515.28	$2515.28
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$2553.67	$2553.67
OXNARD-THOUSAND OAKS-VENTURA (CA)	$2285.64	$2285.64
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$2309.38	$2309.38
NAPA (CA)	$2417.75	$2417.75
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$2522.28	$2522.28
VALLEJO (CA)	$2407.65	$2407.65
BAKERSFIELD (CA)	$2198.80	$2198.80
CHICO (CA)	$2181.54	$2181.54
FRESNO (CA)	$2181.54	$2181.54
HANFORD-CORCORAN (CA)	$2181.54	$2181.54
MADERA (CA)	$2181.54	$2181.54
MERCED (CA)	$2181.54	$2181.54
MODESTO (CA)	$2181.54	$2181.54
REDDING (CA)	$2181.54	$2181.54
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$2247.98	$2247.98
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$2260.25	$2260.25
SALINAS (CA)	$2251.26	$2251.26
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$2582.32	$2582.32
SANTA CRUZ-WATSONVILLE (CA)	$2288.33	$2288.33
SANTA ROSA-PETALUMA (CA)	$2309.50	$2309.50
STOCKTON (CA)	$2181.54	$2181.54
VISALIA (CA)	$2181.54	$2181.54
YUBA CITY (CA)	$2181.54	$2181.54
EL CENTRO (CA)	$2182.57	$2182.57
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$2283.21	$2283.21
SAN LUIS OBISPO-PASO ROBLES (CA)	$2218.52	$2218.52
SANTA MARIA-SANTA BARBARA (CA)	$2253.95	$2253.95
REST OF CALIFORNIA (CA)	$2181.54	$2181.54
COLORADO (CO)	$2198.96	$2198.96
CONNECTICUT (CT)	$2307.43	$2307.43
DC + MD/VA SUBURBS (DC)	$2412.03	$2412.03
DELAWARE (DE)	$2150.15	$2150.15
FORT LAUDERDALE (FL)	$2353.43	$2353.43
MIAMI (FL)	$2526.10	$2526.10
REST OF FLORIDA (FL)	$2241.55	$2241.55
ATLANTA (GA)	$2234.25	$2234.25
REST OF GEORGIA (GA)	$2122.41	$2122.41
HAWAII, GUAM (HI)	$2206.80	$2206.80
IOWA (IA)	$1978.36	$1978.36
IDAHO (ID)	$1998.32	$1998.32
EAST ST. LOUIS (IL)	$2315.90	$2315.90
SUBURBAN CHICAGO (IL)	$2365.82	$2365.82
CHICAGO (IL)	$2454.68	$2454.68
REST OF ILLINOIS (IL)	$2216.93	$2216.93
INDIANA (IN)	$2007.02	$2007.02
KANSAS (KS)	$1990.95	$1990.95
KENTUCKY (KY)	$2062.75	$2062.75
NEW ORLEANS (LA)	$2153.02	$2153.02
REST OF LOUISIANA (LA)	$2068.17	$2068.17
METROPOLITAN BOSTON (MA)	$2365.41	$2365.41
REST OF MASSACHUSETTS (MA)	$2197.24	$2197.24
BALTIMORE/SURR. CNTYS (MD)	$2305.12	$2305.12
REST OF MARYLAND (MD)	$2180.25	$2180.25
SOUTHERN MAINE (ME)	$2091.95	$2091.95
REST OF MAINE (ME)	$2029.03	$2029.03
DETROIT (MI)	$2287.01	$2287.01
REST OF MICHIGAN (MI)	$2127.49	$2127.49
MINNESOTA (MN)	$2055.59	$2055.59
METROPOLITAN ST. LOUIS (MO)	$2134.86	$2134.86
METROPOLITAN KANSAS CITY (MO)	$2118.53	$2118.53
REST OF MISSOURI (MO)	$2051.69	$2051.69
MISSISSIPPI (MS)	$2002.40	$2002.40
MONTANA** (MT)	$2175.32	$2175.32
NORTH CAROLINA (NC)	$2043.71	$2043.71
NORTH DAKOTA** (ND)	$2053.32	$2053.32
NEBRASKA (NE)	$1981.33	$1981.33
NEW HAMPSHIRE (NH)	$2185.24	$2185.24
NORTHERN NJ (NJ)	$2397.26	$2397.26
REST OF NEW JERSEY (NJ)	$2319.23	$2319.23
NEW MEXICO (NM)	$2145.77	$2145.77
NEVADA** (NV)	$2142.18	$2142.18
MANHATTAN (NY)	$2506.84	$2506.84
NYC SUBURBS/LONG ISLAND (NY)	$2585.92	$2585.92
POUGHKPSIE/N NYC SUBURBS (NY)	$2350.65	$2350.65
QUEENS (NY)	$2494.37	$2494.37
REST OF NEW YORK (NY)	$2071.52	$2071.52
OHIO (OH)	$2102.56	$2102.56
OKLAHOMA (OK)	$2037.75	$2037.75
PORTLAND (OR)	$2236.20	$2236.20
REST OF OREGON (OR)	$2111.09	$2111.09
METROPOLITAN PHILADELPHIA (PA)	$2270.74	$2270.74
REST OF PENNSYLVANIA (PA)	$2093.87	$2093.87
PUERTO RICO (PR)	$2182.10	$2182.10
RHODE ISLAND (RI)	$2202.94	$2202.94
SOUTH CAROLINA (SC)	$2079.46	$2079.46
SOUTH DAKOTA** (SD)	$2038.90	$2038.90
TENNESSEE (TN)	$2002.05	$2002.05
BRAZORIA (TX)	$2131.53	$2131.53
DALLAS (TX)	$2153.02	$2153.02
GALVESTON (TX)	$2143.14	$2143.14
HOUSTON (TX)	$2256.08	$2256.08
BEAUMONT (TX)	$2083.70	$2083.70
FORT WORTH (TX)	$2147.10	$2147.10
AUSTIN (TX)	$2204.34	$2204.34
REST OF TEXAS (TX)	$2111.88	$2111.88
UTAH (UT)	$2103.11	$2103.11
VIRGINIA (VA)	$2100.52	$2100.52
VIRGIN ISLANDS (VI)	$2182.10	$2182.10
VERMONT (VT)	$2065.33	$2065.33
SEATTLE (KING CNTY) (WA)	$2388.74	$2388.74
REST OF WASHINGTON (WA)	$2186.49	$2186.49
WISCONSIN (WI)	$1997.00	$1997.00
WEST VIRGINIA (WV)	$2151.89	$2151.89
WYOMING** (WY)	$2122.15	$2122.15

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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 pricing starts with three Relative Value Units (RVUs) assigned to the code: physician work, practice expense, and malpractice. Each RVU component is adjusted by Geographic Practice Cost Indices (GPCIs) specific to the locality where the service is billed, then the adjusted RVUs are summed and multiplied by the annual Medicare conversion factor to produce the allowed amount. The practice-expense RVU differs between non-facility settings (e.g., physician office) and facility settings (e.g., hospital or ASC) because overhead costs differ, so the non-facility and facility amounts can diverge depending on how CMS values that site-of-service difference. The resulting figure is the Medicare-allowed amount before any adjustments for modifiers, multiple-procedure rules, or sequestration.

RVUs — work 33.22, practice expense 25.75 (non-facility) / 25.75 (facility), malpractice 6.17 — × the locality GPCIs × the 2026 conversion factor of $33.40.

Good to know

This is an estimate only — actual payment depends on claim-specific factors like modifiers, place of service, and multiple-procedure reductions.
Medicare typically pays 80% of the allowed amount after the patient meets the Part B deductible; the patient or secondary payer is responsible for the rest.
Annual conversion factor updates, budget-neutrality adjustments, and sequestration can change the amount year to year.
Locality-specific GPCIs mean the national amount shown may not match what a specific Medicare Administrative Contractor (MAC) actually pays.
Always verify current rates and coverage policy with your MAC before billing or appealing a denial.

Frequently asked

Why is there a difference between the facility and non-facility amounts?

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

Why might my actual Medicare payment differ from the national amount shown here?

The national amount uses a GPCI value of 1.0 for all components, while actual payments are adjusted using the GPCIs for the specific locality where the service was rendered, which can raise or lower the amount.

Does this amount represent what the patient owes?

No. This is the total Medicare-allowed amount. Medicare generally pays 80% of this amount after the deductible is met, with the patient or secondary insurance responsible for the remaining 20% plus any unmet deductible.

Does this fee schedule amount account for modifiers or bundling edits?

No. The base PFS amount shown does not reflect adjustments from modifiers, National Correct Coding Initiative (NCCI) edits, multiple-procedure reductions, or other claim-specific factors that can change final reimbursement.

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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.