Medicare Reimbursement for CPT 21295
CPT 21295 is a procedure code reported to Medicare for physician and outpatient billing purposes. This page shows the Medicare Physician Fee Schedule (PFS) estimated allowed amount for 2026, both nationally and adjustable by locality, with separate non-facility and facility rate columns.
Medicare allowed amount (2026)
| Locality | Non-facility | Facility |
|---|---|---|
| National (unadjusted) | $185.04 | $185.04 |
| ALASKA* (AK) | $219.48 | $219.48 |
| ALABAMA (AL) | $166.95 | $166.95 |
| ARKANSAS (AR) | $164.68 | $164.68 |
| ARIZONA (AZ) | $180.24 | $180.24 |
| SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA) | $232.89 | $232.89 |
| SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA) | $237.24 | $237.24 |
| OXNARD-THOUSAND OAKS-VENTURA (CA) | $204.35 | $204.35 |
| LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA) | $205.62 | $205.62 |
| NAPA (CA) | $221.09 | $221.09 |
| SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA) | $233.18 | $233.18 |
| VALLEJO (CA) | $220.67 | $220.67 |
| BAKERSFIELD (CA) | $193.82 | $193.82 |
| CHICO (CA) | $193.06 | $193.06 |
| FRESNO (CA) | $193.06 | $193.06 |
| HANFORD-CORCORAN (CA) | $193.06 | $193.06 |
| MADERA (CA) | $193.06 | $193.06 |
| MERCED (CA) | $193.06 | $193.06 |
| MODESTO (CA) | $193.06 | $193.06 |
| REDDING (CA) | $193.06 | $193.06 |
| RIVERSIDE-SAN BERNARDINO-ONTARIO (CA) | $195.87 | $195.87 |
| SACRAMENTO-ROSEVILLE-FOLSOM (CA) | $201.91 | $201.91 |
| SALINAS (CA) | $201.14 | $201.14 |
| SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA) | $238.45 | $238.45 |
| SANTA CRUZ-WATSONVILLE (CA) | $206.94 | $206.94 |
| SANTA ROSA-PETALUMA (CA) | $208.99 | $208.99 |
| STOCKTON (CA) | $193.06 | $193.06 |
| VISALIA (CA) | $193.06 | $193.06 |
| YUBA CITY (CA) | $193.06 | $193.06 |
| EL CENTRO (CA) | $193.10 | $193.10 |
| SAN DIEGO-CHULA VISTA-CARLSBAD (CA) | $205.37 | $205.37 |
| SAN LUIS OBISPO-PASO ROBLES (CA) | $197.99 | $197.99 |
| SANTA MARIA-SANTA BARBARA (CA) | $201.76 | $201.76 |
| REST OF CALIFORNIA (CA) | $193.06 | $193.06 |
| COLORADO (CO) | $191.21 | $191.21 |
| CONNECTICUT (CT) | $196.92 | $196.92 |
| DC + MD/VA SUBURBS (DC) | $209.75 | $209.75 |
| DELAWARE (DE) | $183.10 | $183.10 |
| FORT LAUDERDALE (FL) | $193.55 | $193.55 |
| MIAMI (FL) | $203.02 | $203.02 |
| REST OF FLORIDA (FL) | $184.37 | $184.37 |
| ATLANTA (GA) | $188.80 | $188.80 |
| REST OF GEORGIA (GA) | $174.34 | $174.34 |
| HAWAII, GUAM (HI) | $197.08 | $197.08 |
| IOWA (IA) | $170.07 | $170.07 |
| IDAHO (ID) | $171.30 | $171.30 |
| EAST ST. LOUIS (IL) | $184.68 | $184.68 |
| SUBURBAN CHICAGO (IL) | $195.27 | $195.27 |
| CHICAGO (IL) | $197.29 | $197.29 |
| REST OF ILLINOIS (IL) | $179.96 | $179.96 |
| INDIANA (IN) | $172.21 | $172.21 |
| KANSAS (KS) | $169.74 | $169.74 |
| KENTUCKY (KY) | $171.59 | $171.59 |
| NEW ORLEANS (LA) | $179.46 | $179.46 |
| REST OF LOUISIANA (LA) | $171.50 | $171.50 |
| METROPOLITAN BOSTON (MA) | $208.84 | $208.84 |
| REST OF MASSACHUSETTS (MA) | $190.34 | $190.34 |
| BALTIMORE/SURR. CNTYS (MD) | $196.45 | $196.45 |
| REST OF MARYLAND (MD) | $186.32 | $186.32 |
| SOUTHERN MAINE (ME) | $180.81 | $180.81 |
| REST OF MAINE (ME) | $172.59 | $172.59 |
| DETROIT (MI) | $186.99 | $186.99 |
| REST OF MICHIGAN (MI) | $176.19 | $176.19 |
| MINNESOTA (MN) | $182.25 | $182.25 |
| METROPOLITAN ST. LOUIS (MO) | $179.56 | $179.56 |
| METROPOLITAN KANSAS CITY (MO) | $177.85 | $177.85 |
| REST OF MISSOURI (MO) | $169.01 | $169.01 |
| MISSISSIPPI (MS) | $166.85 | $166.85 |
| MONTANA** (MT) | $185.02 | $185.02 |
| NORTH CAROLINA (NC) | $174.23 | $174.23 |
| NORTH DAKOTA** (ND) | $179.88 | $179.88 |
| NEBRASKA (NE) | $170.82 | $170.82 |
| NEW HAMPSHIRE (NH) | $188.65 | $188.65 |
| NORTHERN NJ (NJ) | $207.85 | $207.85 |
| REST OF NEW JERSEY (NJ) | $198.90 | $198.90 |
| NEW MEXICO (NM) | $177.28 | $177.28 |
| NEVADA** (NV) | $183.71 | $183.71 |
| MANHATTAN (NY) | $212.64 | $212.64 |
| NYC SUBURBS/LONG ISLAND (NY) | $218.09 | $218.09 |
| POUGHKPSIE/N NYC SUBURBS (NY) | $200.53 | $200.53 |
| QUEENS (NY) | $213.68 | $213.68 |
| REST OF NEW YORK (NY) | $176.73 | $176.73 |
| OHIO (OH) | $175.14 | $175.14 |
| OKLAHOMA (OK) | $170.85 | $170.85 |
| PORTLAND (OR) | $196.52 | $196.52 |
| REST OF OREGON (OR) | $182.00 | $182.00 |
| METROPOLITAN PHILADELPHIA (PA) | $192.53 | $192.53 |
| REST OF PENNSYLVANIA (PA) | $175.17 | $175.17 |
| PUERTO RICO (PR) | $186.17 | $186.17 |
| RHODE ISLAND (RI) | $189.06 | $189.06 |
| SOUTH CAROLINA (SC) | $175.03 | $175.03 |
| SOUTH DAKOTA** (SD) | $179.27 | $179.27 |
| TENNESSEE (TN) | $170.59 | $170.59 |
| BRAZORIA (TX) | $182.59 | $182.59 |
| DALLAS (TX) | $183.91 | $183.91 |
| GALVESTON (TX) | $183.24 | $183.24 |
| HOUSTON (TX) | $188.00 | $188.00 |
| BEAUMONT (TX) | $174.11 | $174.11 |
| FORT WORTH (TX) | $182.87 | $182.87 |
| AUSTIN (TX) | $190.82 | $190.82 |
| REST OF TEXAS (TX) | $178.36 | $178.36 |
| UTAH (UT) | $177.28 | $177.28 |
| VIRGINIA (VA) | $180.54 | $180.54 |
| VIRGIN ISLANDS (VI) | $186.17 | $186.17 |
| VERMONT (VT) | $179.61 | $179.61 |
| SEATTLE (KING CNTY) (WA) | $212.55 | $212.55 |
| REST OF WASHINGTON (WA) | $189.84 | $189.84 |
| WISCONSIN (WI) | $174.22 | $174.22 |
| WEST VIRGINIA (WV) | $173.78 | $173.78 |
| WYOMING** (WY) | $182.78 | $182.78 |
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 Geographic Practice Cost Indices (GPCIs) specific to the locality where the service is performed. The geographically adjusted RVUs are summed and multiplied by the annual national conversion factor to produce the allowed amount. Non-facility rates generally apply when a service is performed in a physician's office, while facility rates apply in hospitals, ASCs, and similar settings, reflecting differences in practice expense inputs; for this code, those practice-expense RVUs are the same in both settings, so the national non-facility and facility amounts shown here are equal. Local adjustments can still cause non-facility and facility amounts to diverge in some localities.
RVUs — work 1.85, practice expense 3.43 (non-facility) / 3.43 (facility), malpractice 0.26 — × the locality GPCIs × the 2026 conversion factor of $33.40.
Good to know
- This is an estimate only, based on the national conversion factor and standard RVUs — actual payment depends on your locality's GPCIs.
- Medicare typically pays 80% of the approved amount after the patient meets their Part B deductible; the beneficiary or secondary payer is responsible for the rest.
- Modifiers, bilateral/multiple procedure rules, sequestration, and annual budget-neutrality adjustments can change the final payment.
- Always verify current rates and coverage rules with your Medicare Administrative Contractor (MAC) before billing.
Frequently asked
Why do non-facility and facility amounts differ for some codes but not others?
The difference comes from practice expense RVUs, which account for overhead like staff and supplies. When a code's practice expense RVU is the same for both settings, as shown here, the resulting allowed amounts are identical.
Does this amount reflect what Medicare actually pays?
No. It reflects the Medicare-approved amount before cost-sharing. Medicare generally pays 80% after the deductible, and your locality's GPCIs may adjust the final figure.
Will this rate change during the year?
The conversion factor and RVUs are typically set annually, but CMS can issue mid-year corrections, and budget-neutrality adjustments or legislation can alter the final conversion factor.
Where can I find the exact rate for my location?
Use the locality-specific GPCI adjustment on this page, or consult your MAC's fee schedule lookup tool for the most precise, locality-adjusted amount.
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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