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CPT 36406 Medicare rate in Q3 2018

Historical · Q3 2018
$16.92

National (GPCI 1.000)

$15.38–$21.23 across payment localities

Participating physician · Before sequestration

CMS evidence · Q3 2018 release

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The national PFS baseline was $16.92 for CPT 36406 in the Office (non-facility) setting and $9.00 in a facility under the Q3 2018 Physician Fee Schedule, effective July 2018. These are the national allowed amounts before locality (GPCI) adjustment; sequestration is excluded.

Why are the facility and non-facility amounts different?

Only the practice-expense RVU changes with the setting. For 36406 it's 0.28 RVUs in the Office (non-facility) setting versus 0.06 in a facility—the whole $7.92 gap between $16.92 and $9.00. In the Office (non-facility) setting the practice bears the overhead, so the allowed amount is higher; in a hospital or ASC the facility bills its own fee, so the professional amount is lower. See facility vs non-facility.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov).

Contract rate as % of Medicare Copy link

Applies to your locality's allowed amount, not the $16.92 national baseline. How to find your contract's percentage.

Need rates from another insurer? Join the waitlist →

Allowed amount, Medicare's share, and patient share Copy link

A physician's $16.92 Office (non-facility) allowed amount: Medicare pays $13.27 after sequestration and the patient owes $3.38, once the Part B deductible is met.

Adjust for your locality →
36406: allowed amount and each party's share by who bills it, Office (non-facility), national baseline
Billed by Allowed amount Participating claim If not participating
What Medicare pays Patient coinsurance Non-participating amount Limiting charge
Physician (MD/DO) 100% Calculator $16.92 $13.27 $13.54 − $0.27 $3.38 $16.07 $18.48

National Q3 2018, GPCI 1.000. Each % applies before the 80/20 split and sequestration.

Is $16.92 what a practice actually receives?

It's the national allowed amount—the starting point. Medicare pays 80% of it ($13.54) and the patient owes 20% coinsurance ($3.38). Sequestration trims Medicare's share by about 2%, your locality's GPCIs scale the total up or down, and the expected-payment calculator applies all three. That payment is practice revenue that covers staff, space, equipment, and billing. It isn't the clinician's take-home pay. The practice-expense RVU above is CMS's estimate of that overhead share.

Sources: Budget Control Act sequestration provisions; CMS Medicare Fee-for-Service payment guidance; CMS Geographic Practice Cost Index (GPCI) files; CMS Physician Fee Schedule overview (cms.gov).

What's the non-participating amount for 36406?

$16.07 in the Office (non-facility) setting—95% of the $16.92 participating fee schedule amount above. A participating provider takes the fee schedule amount as payment in full on every claim. A non-participating provider is paid this reduced amount, but chooses claim by claim whether to accept assignment. See participating vs non-participating.

Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.

What's the limiting charge for 36406?

$18.48 in the Office (non-facility) setting—the ceiling on what a non-participating provider can bill the patient on an unassigned claim. That's 109.25% of the $16.92 amount above. The non-participating amount is 95% of the fee schedule rate ($16.07), and the statutory cap is 115% of that. See limiting charge.

Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.

CMS RVU18CJuly 1 – September 30, 2018 See file rows

Which billing rules and modifiers apply? Copy link

CMS indicators that apply to 36406: MULT PROC 2 (standard reduction applies).

Multiple procedures

Standard reduction applies

MULT PROC

2

When billed with other procedures on the same date, the highest-valued one is paid at 100% and the next four at 50% each.

-51 depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one.

Global surgery period XXX (does not apply). Not payable with 36406: -26/TC · -50 · -80/81/82 · -AS · -62 · -66.

Why would a Medicare claim for 36406 be denied or paid less?

These come from CMS indicators on this page, not general billing advice.

Payer-specific coverage and documentation rules live outside these files, so a claim that clears every check here can still be denied on other grounds.

CMS RVU18CJuly 1 – September 30, 2018 See file rows

Can you bill it with another code? Copy link

This code

36406

See every current NCCI pair for 36406 →

Payment review for 36406 Copy link

Checking a paid 36406 line?

Check an actual payment Model this code in a contract
What to check (4)

Three published payment rules can change what 36406 allows on a claim: the office/facility differential, the standard multiple-procedure reduction and the assistant-at-surgery prohibition. Each is a legitimate reason for a paid amount to differ from the fee-schedule amount on this page.

  • Check the place-of-service code before attributing the gap to the payer: office and facility pricing differ by $7.92 nationally at GPCI 1.000, before any locality adjustment.
  • Rank the claim’s procedure lines before calling this one short-paid: billed with a higher-valued procedure on the same date, its allowed amount is $8.46 instead of $16.92 (national, GPCI 1.000). That is the rule, not a payer error.
  • Expect an assistant-at-surgery denial here rather than appealing it—a -80 or -AS line on this procedure is never separately payable.
  • Reprice the line against the release, locality, setting, modifier and participation status that applied to the date of service before treating any difference as an underpayment.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov); CMS Medicare Claims Processing Manual (Pub. 100-04); 42 USC 1395w-4(i)(2) (SSA §1848(i)(2))—Assistants-at-surgery.

How location and RVUs set the amount Copy link

Office (non-facility): 0.47 RVUs × $35.9996 = $16.92 national PFS baseline. Local GPCIs move it from $15.38 in Mississippi, MS to $21.23 in Alaska, AK.

Office (non-facility)

Office (non-facility): each RVU times its GPCI, summed, times the conversion factor
Component RVU × GPCI =
Work 0.18 1.000 0.18
Practice expense 0.28 1.000 0.28
Malpractice 0.01 1.000 0.01
Total RVUs 0.47
× Conversion factor $35.9996
= National PFS baseline $16.92

Facility

Facility: each RVU times its GPCI, summed, times the conversion factor
Component RVU × GPCI =
Work 0.18 1.000 0.18
Practice expense 0.06 1.000 0.06
Malpractice 0.01 1.000 0.01
Total RVUs 0.25
× Conversion factor $35.9996
= National PFS baseline $9.00

Rates by locality Copy link

Maine: $16.01–$16.87 across 2 localities ME Wisconsin: $16.25 WI Vermont: $16.93 VT New Hampshire: $17.39 NH Montana: $17.15 MT North Dakota: $16.75 ND Minnesota: $16.80 MN Michigan: $16.11–$17.06 across 2 localities MI New York: $16.27–$19.68 across 5 localities NY Massachusetts: $17.75–$18.96 across 2 localities MA Rhode Island: $17.60 RI Washington: $17.00–$18.54 across 2 localities WA Idaho: $15.76 ID Wyoming: $16.88 WY South Dakota: $16.70 SD Iowa: $15.77 IA Illinois: $16.18–$17.72 across 4 localities IL Indiana: $15.88 IN Ohio: $16.08 OH Pennsylvania: $16.29–$17.94 across 2 localities PA New Jersey: $18.29–$18.98 across 2 localities NJ Connecticut: $18.28 CT Oregon: $16.51–$17.45 across 2 localities OR Nevada: $17.07 NV Utah: $16.24 UT Colorado: $17.12 CO Nebraska: $15.77 NE Missouri: $15.54–$16.57 across 3 localities MO Kentucky: $15.65 KY West Virginia: $15.58 WV Virginia: $16.75 VA Maryland: $17.34–$18.13 across 2 localities MD Delaware: $17.20 DE California: $17.64–$20.81 across 32 localities CA Arizona: $16.57 AZ New Mexico: $16.21 NM Kansas: $15.88 KS Oklahoma: $15.80 OK Arkansas: $15.48 AR Tennessee: $15.75 TN North Carolina: $16.11 NC South Carolina: $15.87 SC District of Columbia: $19.37 DC Texas: $16.10–$17.15 across 8 localities TX Louisiana: $15.85–$16.68 across 2 localities LA Mississippi: $15.38 MS Alabama: $15.63 AL Georgia: $15.93–$16.92 across 2 localities GA Florida: $16.56–$17.78 across 3 localities FL Alaska: $21.23 AK Hawaii: $18.26 HI
$15–$16 $16–$17 $17–$18 $18–$19 $19–$20 $20–$21

36406 Office (non-facility) by metro, highest first

Anchorage, AK $21.23 Locality 02102-01 San Jose, CA $20.81 Locality 01112-09 San Francisco, CA $20.47 Locality 01112-05 Queens, NY $19.68 Locality 13292-04 Long Island, NY $19.67 Locality 13202-02 Washington, DC $19.37 Locality 12202-01
Show 56 more metros
New York City, NY $19.29 Locality 13202-01 Northern New Jersey, NJ $18.98 Locality 12402-01 Boston, MA $18.96 Locality 14212-01 Los Angeles, CA $18.89 Locality 01182-18 Ventura County, CA $18.73 Locality 01182-17 Seattle, WA $18.54 Locality 02402-02 Hartford, CT $18.28 Locality 13102-00 Honolulu, HI $18.26 Locality 01212-01 Baltimore, MD $18.13 Locality 12302-01 Philadelphia, PA $17.94 Locality 12502-01 San Diego, CA $17.93 Locality 01182-72 Sacramento, CA $17.79 Locality 01112-63 Miami, FL $17.78 Locality 09102-04 Suburban Chicago, IL $17.72 Locality 06102-15 Riverside, CA $17.68 Locality 01112-62 Bakersfield, CA $17.65 Locality 01112-54 Chicago, IL $17.65 Locality 06102-16 Fresno, CA $17.64 Locality 01112-56 Providence, RI $17.60 Locality 14412-01 Portland, OR $17.45 Locality 02302-01 Fort Lauderdale, FL $17.33 Locality 09102-03 Houston, TX $17.15 Locality 04412-18 Denver, CO $17.12 Locality 04112-01 Las Vegas, NV $17.07 Locality 01312-00 Detroit, MI $17.06 Locality 08202-01 Dallas, TX $17.06 Locality 04412-11 Austin, TX $17.04 Locality 04412-31 Atlanta, GA $16.92 Locality 10212-01 Portland, ME $16.87 Locality 14112-03 Minneapolis, MN $16.80 Locality 06202-00 Richmond, VA $16.75 Locality 11302-00 Fort Worth, TX $16.73 Locality 04412-28 New Orleans, LA $16.68 Locality 07202-01 Phoenix, AZ $16.57 Locality 03102-00 Kansas City, MO $16.57 Locality 05302-02 Tampa, FL $16.56 Locality 09102-99 Metro East, IL $16.56 Locality 06102-12 St. Louis, MO $16.53 Locality 05302-01 Pittsburgh, PA $16.29 Locality 12502-99 Buffalo, NY $16.27 Locality 13282-99 Milwaukee, WI $16.25 Locality 06302-00 Salt Lake City, UT $16.24 Locality 03502-09 San Antonio, TX $16.22 Locality 04412-99 Albuquerque, NM $16.21 Locality 04212-05 Charlotte, NC $16.11 Locality 11502-00 Columbus, OH $16.08 Locality 15202-00 Indianapolis, IN $15.88 Locality 08102-00 Wichita, KS $15.88 Locality 05202-00 Charleston, SC $15.87 Locality 11202-01 Oklahoma City, OK $15.80 Locality 04312-00 Des Moines, IA $15.77 Locality 05102-00 Omaha, NE $15.77 Locality 05402-00 Boise, ID $15.76 Locality 02202-00 Nashville, TN $15.75 Locality 10312-35 Louisville, KY $15.65 Locality 15102-00 Birmingham, AL $15.63 Locality 10112-00
Maine: $8.71–$8.90 across 2 localities ME Wisconsin: $8.67 WI Vermont: $8.89 VT New Hampshire: $9.12 NH Montana: $9.23 MT North Dakota: $8.83 ND Minnesota: $8.79 MN Michigan: $8.83–$9.22 across 2 localities MI New York: $8.75–$10.17 across 5 localities NY Massachusetts: $9.30–$9.62 across 2 localities MA Rhode Island: $9.28 RI Washington: $8.99–$9.47 across 2 localities WA Idaho: $8.61 ID Wyoming: $8.96 WY South Dakota: $8.78 SD Iowa: $8.59 IA Illinois: $8.90–$9.46 across 4 localities IL Indiana: $8.60 IN Ohio: $8.82 OH Pennsylvania: $8.87–$9.44 across 2 localities PA New Jersey: $9.40–$9.63 across 2 localities NJ Connecticut: $9.47 CT Oregon: $8.85–$9.10 across 2 localities OR Nevada: $9.02 NV Utah: $8.90 UT Colorado: $9.05 CO Nebraska: $8.56 NE Missouri: $8.70–$8.95 across 3 localities MO Kentucky: $8.68 KY West Virginia: $8.80 WV Virginia: $8.94 VA Maryland: $9.16–$9.46 across 2 localities MD Delaware: $9.13 DE California: $9.13–$10.08 across 32 localities CA Arizona: $8.88 AZ New Mexico: $8.92 NM Kansas: $8.67 KS Oklahoma: $8.75 OK Arkansas: $8.57 AR Tennessee: $8.62 TN North Carolina: $8.74 NC South Carolina: $8.65 SC District of Columbia: $9.83 DC Texas: $8.78–$9.13 across 8 localities TX Louisiana: $8.83–$9.02 across 2 localities LA Mississippi: $8.49 MS Alabama: $8.58 AL Georgia: $8.81–$9.03 across 2 localities GA Florida: $9.03–$9.63 across 3 localities FL Alaska: $12.39 AK Hawaii: $9.18 HI
$8–$9 $9–$10 $10–$10 $10–$11 $11–$12 $12–$12

36406 Facility by metro, highest first

Anchorage, AK $12.39 Locality 02102-01 Queens, NY $10.17 Locality 13292-04 Long Island, NY $10.12 Locality 13202-02 San Jose, CA $10.08 Locality 01112-09 San Francisco, CA $9.98 Locality 01112-05 New York City, NY $9.95 Locality 13202-01
Show 56 more metros
Washington, DC $9.83 Locality 12202-01 Miami, FL $9.63 Locality 09102-04 Northern New Jersey, NJ $9.63 Locality 12402-01 Boston, MA $9.62 Locality 14212-01 Los Angeles, CA $9.57 Locality 01182-18 Hartford, CT $9.47 Locality 13102-00 Seattle, WA $9.47 Locality 02402-02 Chicago, IL $9.46 Locality 06102-16 Baltimore, MD $9.46 Locality 12302-01 Philadelphia, PA $9.44 Locality 12502-01 Ventura County, CA $9.42 Locality 01182-17 Suburban Chicago, IL $9.38 Locality 06102-15 Fort Lauderdale, FL $9.31 Locality 09102-03 Providence, RI $9.28 Locality 14412-01 Detroit, MI $9.22 Locality 08202-01 San Diego, CA $9.21 Locality 01182-72 Sacramento, CA $9.19 Locality 01112-63 Riverside, CA $9.18 Locality 01112-62 Honolulu, HI $9.18 Locality 01212-01 Bakersfield, CA $9.14 Locality 01112-54 Metro East, IL $9.14 Locality 06102-12 Fresno, CA $9.13 Locality 01112-56 Houston, TX $9.13 Locality 04412-18 Portland, OR $9.10 Locality 02302-01 Denver, CO $9.05 Locality 04112-01 Tampa, FL $9.03 Locality 09102-99 Atlanta, GA $9.03 Locality 10212-01 New Orleans, LA $9.02 Locality 07202-01 Las Vegas, NV $9.02 Locality 01312-00 Dallas, TX $9.02 Locality 04412-11 Kansas City, MO $8.95 Locality 05302-02 Austin, TX $8.95 Locality 04412-31 Richmond, VA $8.94 Locality 11302-00 St. Louis, MO $8.93 Locality 05302-01 Albuquerque, NM $8.92 Locality 04212-05 Fort Worth, TX $8.92 Locality 04412-28 Portland, ME $8.90 Locality 14112-03 Salt Lake City, UT $8.90 Locality 03502-09 Phoenix, AZ $8.88 Locality 03102-00 Pittsburgh, PA $8.87 Locality 12502-99 Columbus, OH $8.82 Locality 15202-00 Minneapolis, MN $8.79 Locality 06202-00 San Antonio, TX $8.79 Locality 04412-99 Buffalo, NY $8.75 Locality 13282-99 Oklahoma City, OK $8.75 Locality 04312-00 Charlotte, NC $8.74 Locality 11502-00 Louisville, KY $8.68 Locality 15102-00 Wichita, KS $8.67 Locality 05202-00 Milwaukee, WI $8.67 Locality 06302-00 Charleston, SC $8.65 Locality 11202-01 Nashville, TN $8.62 Locality 10312-35 Boise, ID $8.61 Locality 02202-00 Indianapolis, IN $8.60 Locality 08102-00 Des Moines, IA $8.59 Locality 05102-00 Birmingham, AL $8.58 Locality 10112-00 Omaha, NE $8.56 Locality 05402-00

Q3 2018, each locality's GPCIs, before sequestration. Multi-locality states are shaded by their mean. Look up your exact locality →

CMS RVU18CJuly 1 – September 30, 2018 See file rows

Source & method Copy link

  1. 01 PPRRVU18_JUL.csv · Q3 2018 (RVU18C) · row 8,401—status A, RVUs limits
    Source
    Physician relative value file (PPRRVU), Q3 2018 release
    Effective
    July 1 – September 30, 2018
    Locator
    PPRRVU18_JUL.csv in rvu18c1.zip · row 8,401 of 16,668 · via CMS
    Fields read
    Status A (col 4) Work RVU 0.18 (col 6) Office (non-facility) PE RVU 0.28 (col 7) Facility PE RVU 0.06 (col 9) Malpractice RVU 0.01 (col 11)
    SHA-256 514e3c115f8e62a3…
    Doesn’t establish
    A locality-adjusted allowed amount, or the payment after sequestration. National baselines use GPCI 1.000 and exclude sequestration.
    Note
    Whether a national amount exists depends on the status and CMS’s payment instructions; blank RVUs are never treated as zero.
  2. 02 Conversion factor · same file · row 8,401 · column 25—$35.9996
    Source
    Conversion factor, read from the same file as the RVUs

Cite this rate

CPT 36406 National PFS baseline: Office (non-facility) $16.92; Facility $9.00 (Q3 2018; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU18C, PPRRVU18_JUL.csv row 8,401. Localis. https://localishealth.com/cpt/36406/2018/C

Past releases are never edited, so the citation stays checkable after CMS publishes a newer one. Methodology · Plain-text summary · JSON

How has it changed? Copy link

$18.37 Office (non-facility) and $7.68 Facility since Jan 1, 2026, after a +7.2% increase in the Office (non-facility) amount. -8.5% decrease since Q1 2013; peak $20.84 in Q4 2015.

  1. Jan 1, 2026 – present

    Q1 2026

    Still in effect · 4 releases at this rate
    Office
    $18.37 (+$1.23, +7.2% increase)
    Facility
    $7.68 (−$0.73, -8.7% decrease)

    Q1 2026 Jan 1, 2026 – Mar 31, 2026 · Q2 2026 Apr 1, 2026 – Jun 30, 2026 · Q3 2026 Jul 1, 2026 – Sep 30, 2026 · Q4 2026 Oct 1, 2026 – present

  2. Jan 1, 2025 – Dec 31, 2025

    Q1 2025

    4 releases at this rate
    Office
    $17.14 (−$0.50, -2.8% decrease)
    Facility
    $8.41 (−$0.24, -2.8% decrease)

    Q1 2025 Jan 1, 2025 – Mar 31, 2025 · Q2 2025 Apr 1, 2025 – Jun 30, 2025 · Q3 2025 Jul 1, 2025 – Sep 30, 2025 · Q4 2025 Oct 1, 2025 – Dec 31, 2025

  3. Mar 9, 2024 – Dec 31, 2024

    Q1 2024

    4 releases at this rate
    Office
    $17.64 (+$0.29, +1.7% increase)
    Facility
    $8.65 (+$0.14, +1.6% increase)

    Q1 2024 Mar 9, 2024 – Mar 31, 2024 · Q2 2024 Apr 1, 2024 – Jun 30, 2024 · Q3 2024 Jul 1, 2024 – Sep 30, 2024 · Q4 2024 Oct 1, 2024 – Dec 31, 2024

  4. Jan 1, 2024 – Mar 8, 2024 · Superseded revision

    Q1 2024 rev 1

    Revision 1, later corrected by CMS
    Office
    $17.35
    Facility
    $8.51

  5. Jan 1, 2023 – Dec 31, 2023

    Q1 2023

    4 releases at this rate
    Office
    $17.62 (−$0.03, -0.2% decrease)
    Facility
    $8.81 (−$0.19, -2.1% decrease)

    Q1 2023 Jan 1, 2023 – Mar 31, 2023 · Q2 2023 Apr 1, 2023 – Jun 30, 2023 · Q3 2023 Jul 1, 2023 – Sep 30, 2023 · Q4 2023 Oct 1, 2023 – Dec 31, 2023

  6. Jan 1, 2022 – Dec 31, 2022

    Q1 2022

    4 releases at this rate
    Office
    $17.65 (+$0.20, +1.1% increase)
    Facility
    $9.00 (+$0.28, +3.2% increase)

    Q1 2022 Jan 1, 2022 – Mar 31, 2022 · Q2 2022 Apr 1, 2022 – Jun 30, 2022 · Q3 2022 Jul 1, 2022 – Sep 30, 2022 · Q4 2022 Oct 1, 2022 – Dec 31, 2022

National baseline (GPCI 1.000), before sequestration.

How each change is split
The chips under each change split the Office (non-facility) move into the conversion factor's share, which CMS sets for every code, and 36406's own work, practice-expense and malpractice RVUs. CMS doesn't publish this split; we derive it from each release's RVUs and conversion factor. We apply the new conversion factor to the earlier RVUs first, then price each RVU change at the new conversion factor. Another order would move a few cents between columns, but every total stays the same.
When does this rate change?

CMS publishes a fee schedule release every quarter (January, April, July, October), and each is versioned here. See what changed each release, or get an email when a new release moves rates.

The 36406 rate last moved in Q1 2026. See its rate history.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files.

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