Medicare Reimbursement for CPT 21431

CPT 21431 is a procedure code billed under the Medicare Physician Fee Schedule (PFS); the official descriptor is not reproduced here due to AMA licensing. This page shows the estimated Medicare-allowed amount for this code nationally and by locality, with separate figures for non-facility (e.g., office) and facility (e.g., hospital) settings.

Medicare allowed amount (2026)

Locality	Non-facility	Facility
National (unadjusted)	$646.98	$646.98
ALASKA* (AK)	$785.80	$785.80
ALABAMA (AL)	$589.17	$589.17
ARKANSAS (AR)	$581.90	$581.90
ARIZONA (AZ)	$631.57	$631.57
SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) (CA)	$802.27	$802.27
SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) (CA)	$816.84	$816.84
OXNARD-THOUSAND OAKS-VENTURA (CA)	$708.69	$708.69
LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) (CA)	$713.60	$713.60
NAPA (CA)	$763.32	$763.32
SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) (CA)	$803.27	$803.27
VALLEJO (CA)	$761.88	$761.88
BAKERSFIELD (CA)	$674.97	$674.97
CHICO (CA)	$672.31	$672.31
FRESNO (CA)	$672.31	$672.31
HANFORD-CORCORAN (CA)	$672.31	$672.31
MADERA (CA)	$672.31	$672.31
MERCED (CA)	$672.31	$672.31
MODESTO (CA)	$672.31	$672.31
REDDING (CA)	$672.31	$672.31
RIVERSIDE-SAN BERNARDINO-ONTARIO (CA)	$681.88	$681.88
SACRAMENTO-ROSEVILLE-FOLSOM (CA)	$701.34	$701.34
SALINAS (CA)	$698.61	$698.61
SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) (CA)	$820.92	$820.92
SANTA CRUZ-WATSONVILLE (CA)	$716.22	$716.22
SANTA ROSA-PETALUMA (CA)	$723.22	$723.22
STOCKTON (CA)	$672.31	$672.31
VISALIA (CA)	$672.31	$672.31
YUBA CITY (CA)	$672.31	$672.31
EL CENTRO (CA)	$672.45	$672.45
SAN DIEGO-CHULA VISTA-CARLSBAD (CA)	$711.87	$711.87
SAN LUIS OBISPO-PASO ROBLES (CA)	$687.80	$687.80
SANTA MARIA-SANTA BARBARA (CA)	$700.36	$700.36
REST OF CALIFORNIA (CA)	$672.31	$672.31
COLORADO (CO)	$666.69	$666.69
CONNECTICUT (CT)	$686.04	$686.04
DC + MD/VA SUBURBS (DC)	$728.34	$728.34
DELAWARE (DE)	$640.97	$640.97
FORT LAUDERDALE (FL)	$675.41	$675.41
MIAMI (FL)	$706.69	$706.69
REST OF FLORIDA (FL)	$645.90	$645.90
ATLANTA (GA)	$659.42	$659.42
REST OF GEORGIA (GA)	$613.70	$613.70
HAWAII, GUAM (HI)	$683.98	$683.98
IOWA (IA)	$598.62	$598.62
IDAHO (ID)	$602.65	$602.65
EAST ST. LOUIS (IL)	$647.95	$647.95
SUBURBAN CHICAGO (IL)	$681.20	$681.20
CHICAGO (IL)	$688.64	$688.64
REST OF ILLINOIS (IL)	$632.17	$632.17
INDIANA (IN)	$605.56	$605.56
KANSAS (KS)	$597.80	$597.80
KENTUCKY (KY)	$604.47	$604.47
NEW ORLEANS (LA)	$629.71	$629.71
REST OF LOUISIANA (LA)	$604.30	$604.30
METROPOLITAN BOSTON (MA)	$724.20	$724.20
REST OF MASSACHUSETTS (MA)	$664.22	$664.22
BALTIMORE/SURR. CNTYS (MD)	$684.37	$684.37
REST OF MARYLAND (MD)	$651.46	$651.46
SOUTHERN MAINE (ME)	$632.89	$632.89
REST OF MAINE (ME)	$607.03	$607.03
DETROIT (MI)	$654.53	$654.53
REST OF MICHIGAN (MI)	$619.41	$619.41
MINNESOTA (MN)	$636.73	$636.73
METROPOLITAN ST. LOUIS (MO)	$629.74	$629.74
METROPOLITAN KANSAS CITY (MO)	$624.32	$624.32
REST OF MISSOURI (MO)	$596.48	$596.48
MISSISSIPPI (MS)	$589.21	$589.21
MONTANA** (MT)	$646.92	$646.92
NORTH CAROLINA (NC)	$612.22	$612.22
NORTH DAKOTA** (ND)	$629.52	$629.52
NEBRASKA (NE)	$600.94	$600.94
NEW HAMPSHIRE (NH)	$658.08	$658.08
NORTHERN NJ (NJ)	$722.84	$722.84
REST OF NEW JERSEY (NJ)	$693.27	$693.27
NEW MEXICO (NM)	$622.97	$622.97
NEVADA** (NV)	$642.43	$642.43
MANHATTAN (NY)	$739.04	$739.04
NYC SUBURBS/LONG ISLAND (NY)	$756.74	$756.74
POUGHKPSIE/N NYC SUBURBS (NY)	$698.96	$698.96
QUEENS (NY)	$742.02	$742.02
REST OF NEW YORK (NY)	$620.23	$620.23
OHIO (OH)	$615.86	$615.86
OKLAHOMA (OK)	$601.86	$601.86
PORTLAND (OR)	$683.57	$683.57
REST OF OREGON (OR)	$636.80	$636.80
METROPOLITAN PHILADELPHIA (PA)	$672.05	$672.05
REST OF PENNSYLVANIA (PA)	$615.81	$615.81
PUERTO RICO (PR)	$650.50	$650.50
RHODE ISLAND (RI)	$660.58	$660.58
SOUTH CAROLINA (SC)	$615.18	$615.18
SOUTH DAKOTA** (SD)	$627.46	$627.46
TENNESSEE (TN)	$600.57	$600.57
BRAZORIA (TX)	$639.32	$639.32
DALLAS (TX)	$643.67	$643.67
GALVESTON (TX)	$641.45	$641.45
HOUSTON (TX)	$657.56	$657.56
BEAUMONT (TX)	$612.45	$612.45
FORT WORTH (TX)	$640.45	$640.45
AUSTIN (TX)	$665.04	$665.04
REST OF TEXAS (TX)	$625.74	$625.74
UTAH (UT)	$622.35	$622.35
VIRGINIA (VA)	$632.21	$632.21
VIRGIN ISLANDS (VI)	$650.50	$650.50
VERMONT (VT)	$628.85	$628.85
SEATTLE (KING CNTY) (WA)	$736.27	$736.27
REST OF WASHINGTON (WA)	$662.39	$662.39
WISCONSIN (WI)	$611.50	$611.50
WEST VIRGINIA (WV)	$612.43	$612.43
WYOMING** (WY)	$639.33	$639.33

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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 — assigned to the code. Each RVU component is adjusted by Geographic Practice Cost Indices (GPCIs) specific to the locality where the service is furnished, to reflect regional cost differences. The adjusted RVUs are summed and multiplied by the annual Medicare conversion factor to produce the allowed amount. Practice-expense RVUs differ between non-facility and facility settings, which is why the same code can have two different allowed amounts depending on place of service.

RVUs — work 7.7, practice expense 10.79 (non-facility) / 10.79 (facility), malpractice 0.88 — × the locality GPCIs × the 2026 conversion factor of $33.40.

Good to know

This is an estimate only, not a guarantee of payment or coverage.
Medicare typically pays 80% of the allowed amount after the patient meets the annual deductible; the patient or secondary payer is responsible for the rest.
Modifiers, multiple-procedure reductions, sequestration, and annual budget-neutrality adjustments can change the actual paid amount.
Amounts vary by locality based on GPCI adjustments; always confirm with your Medicare Administrative Contractor (MAC) for the applicable locality.
Fee schedule values are updated annually and may change mid-year due to legislative or regulatory action.

Frequently asked

Why does CPT 21431 show different amounts for non-facility and facility settings?

The practice-expense RVU component differs based on place of service because overhead costs (staff, supplies, equipment) are treated differently when the service is performed in a facility versus a non-facility setting like an office.

Does this amount reflect what Medicare will actually pay?

No. It reflects the PFS allowed amount before adjustments such as deductible status, coinsurance, modifiers, sequestration, and locality-specific GPCI variation. Actual payment may differ.

Why do allowed amounts vary by locality for the same code?

Geographic Practice Cost Indices (GPCIs) adjust the work, practice-expense, and malpractice RVUs to reflect differences in local labor, rent, and liability costs, which changes the final calculated amount by locality.

Where can I verify the exact rate for my locality?

Check the current year's Medicare Physician Fee Schedule lookup tool or confirm with your Medicare Administrative Contractor (MAC), since rates can be updated or corrected after initial publication.

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.