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Medicare Physician Fee Schedule Effective Locality 12302-01 CMS RVU26D Updated

CPT 42820 Medicare rate in Baltimore, MD

42820 Q4 2026
Office (non-facility) Facility
Locality-adjusted allowed amount
$275.31
in a doctor’s own office or clinic

Baltimore, MD flag Baltimore, MD (Locality 12302-01)

5.5% above the national baseline ($260.86)

CMS evidence · Q4 2026 release

Participating provider, no modifiers, whole service, before sequestration. Change these

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The Medicare allowed amount is $275.31 in the Office (non-facility) and Facility settings, under the Q4 2026 Physician Fee Schedule. This is the fee schedule amount before sequestration and before any deductible or coinsurance is applied—not necessarily what a specific claim pays.

What Medicare locality is Baltimore, MD in? Copy link

Baltimore, MD is in CMS payment locality Baltimore/Surr. Counties (12302-01). The same amount applies everywhere in it.

Confirm the locality before using this amount. A split ZIP needs ZIP+4 for an exact match.

ZIP codes in this payment locality (202)

The CMS ZIP-to-locality crosswalk maps 202 ZIP codes to this payment locality. Use this amount only after you confirm the service location is in this locality. Of these, 5 span more than one locality and need ZIP+4 for an exact match.

20588 20701 20711 20723 20724 20733 20751 20755 20758 20759 20763 20764 20765 20776 20777 20778 20779 20794 21001 21005 21009 21010 21012 21013 21014 21015 21017 21018 21020 21022 21023 21027 21028 21029 21030 21031 21032 21034 21035 21036 21037 21040 21041 21042 21043 21044 21045 21046 21047 21048 21050 21051 21052 21053 21054 21055 21056 21057 21060 21061 21062 21065 21071 21074 21075 21076 21077 21078 21080 21082 21084 21085 21087 21088 21090 21092 21093 21094 21098 21102 21104 21105 21106 21108 21111 21113 21114 21117 21120 21122 21123 21128 21130 21131 21132 21133 21136 21139 21140 21144

102 more ZIP codes map to this locality. The Baltimore, MD locality page lists the full set.

Which ZIP codes does the Baltimore, MD rate for 42820 cover?

The CMS ZIP-to-locality crosswalk maps 202 ZIP codes to this payment locality, and 42820 has the same amount in every one of them. Examples include 20588, 20701, 20711, 20723, 20724, 20733. Of these, 5 span more than one payment locality and need ZIP+4 for an exact match.

How the Baltimore, MD amount is calculated Copy link

How locality affects the amount Copy link

Office (non-facility) · Q4 2026 · Participating · Whole service

Baltimore, MD's $275.31 compares with the $260.86 national PFS baseline (GPCI 1.000). Each of this locality's geographic practice cost indices (GPCIs) scales one RVU component before the conversion factor is applied. Together they put Baltimore, MD 5.5% above the national baseline.

Baltimore, MD ranks #27 of 109 Medicare payment localities for 42820, where #1 has the highest allowed amount. Within Maryland it's #1 of 2: $13.45 (5.1%) higher than Rest of Maryland ($261.86).

Work GPCI
1.016
+$2.20 vs. national
Practice expense GPCI
1.073
+$7.58 vs. national
Malpractice GPCI
1.237
+$4.67 vs. national
2026 conversion factor
$33.4009

Each figure is that GPCI's share of the +$14.45 gap from the national baseline: its RVUs for 42820 × (GPCI − 1.000) × the conversion factor. Practice expense accounts for the most, +$7.58.

CMS RVU26DOctober 1 – December 31, 2026revision 2 See file rows

Show the full calculation and CMS rows

For the office (non-facility) amount, each of 42820's RVU components is multiplied by its Baltimore, MD GPCI; the products are summed and multiplied by the conversion factor.

Code
42820
DOS
Not selected; uses this release’s rates
Locality
Baltimore/Surr. Counties (12302-01)
Setting
Office (non-facility)
Participation
Participating provider
Modifiers
None
Units
1
Release
Q4 2026, revision 2
Sequestration
Shown separately from the allowed amount

Formula

(work_rvu × work_gpci + pe_rvu × pe_gpci + mp_rvu × mp_gpci) × conversion_factor

Localis calculated this from CMS’s published inputs. Select an underlined value to see where it comes from.

RVU × GPCI components of Baltimore, MD allowed amount for 42820
Component RVU × GPCI = Adjusted
Work 4.11 × 1.016 4.1758
Practice expense · Office (non-facility) 3.11 × 1.073 3.3370
Malpractice 0.59 × 1.237 0.7298
Sum of adjusted RVUs 8.2426
× 33.4009 conversion factor = formula amount $275.31

Component subtotals show four decimals. The formula amount is rounded to cents before any later adjustment.

  1. Locality-adjusted allowed amount $275.31

    After applicable fee-schedule adjustments; sequestration excluded

Citations

  • 42820’s RVUs, PFS status and conversion factor

    Physician relative value file (PPRRVU)CMS RVU26DOctober 1 – December 31, 2026revision 2

    PPRRVU2026_Oct_nonQPP.csv row 5,079 in rvu26d-updated-08-26-2026.zip

    A HCPCS
    42820
    B Modifier
    blank
    D Status code
    A
    F Work RVU
    4.11
    G Non-facility PE RVU
    3.11
    K MP RVU
    0.59
    Z Conversion factor
    33.4009
    In the CMS file

    Loading rows 5,077–5,081 of PPRRVU2026_Oct_nonQPP.csv…

    Download rvu26d-updated-08-26-2026.zip from CMS File fingerprint 4d0d3f19bd954ffc0f5b8439169d267da023d4f6911f4539bb6e98723cb1a626

  • Locality 12302-01’s GPCIs

    Geographic practice cost indices (GPCI)CMS RVU26DOctober 1 – December 31, 2026revision 2

    GPCI2026.csv row 60 in rvu26d-updated-08-26-2026.zip

    A MAC
    12302
    C Locality number
    01
    E Work GPCI
    1.016
    F PE GPCI
    1.073
    G MP GPCI
    1.237
    In the CMS file

    Loading rows 58–62 of GPCI2026.csv…

    Download rvu26d-updated-08-26-2026.zip from CMS File fingerprint 7850e2987d12e46930e49033f96829b5ae11f60dd1f19965329b38cf08b05264

Why is the 42820 rate in Baltimore, MD different from the national amount?

The national figure is a GPCI 1.000 baseline, not an amount any provider is paid. This locality's geographic practice cost indices—work 1.016, practice expense 1.073, malpractice 1.237—scale each RVU component before the conversion factor is applied, which is why the Baltimore, MD amount is higher than the $260.86 baseline.

42820 in Baltimore, MD since Q4 2025 Copy link

Office (non-facility) · Participating · Whole service

The allowed amount went from $306.63 in Q4 2025 to $275.31 in Q4 2026, −$31.32 (-10.2%). The national baseline moved -9.3% over the same period.

What changed 42820's allowed amount in Baltimore, MD between Q4 2025 and Q4 2026
What moved Effect
Conversion factor National: the dollar multiplier CMS sets each year. +$10.00
42820's RVUs National: CMS revalued the code itself. −$38.83
Baltimore, MD's GPCIs Local: this payment locality's cost indices. −$2.49
Total change −$31.32

A derived breakdown of the two releases' formula inputs, applied in order: the conversion factor on Q4 2025's RVUs and GPCIs, then 42820's new RVUs, then this locality's new GPCIs. A different order moves a few cents between rows; the total is exact.

Which amount applies to your claim? Copy link

Who pays what Copy link

Medicare pays part of the Baltimore, MD allowed amount and the patient pays the rest. A provider who doesn’t participate in Medicare is allowed less, and can bill the patient up to a ceiling.

Computed from the Q4 2026 CMS release

Allowed amount

The fee-schedule amount for 42820 in the Office (non-facility) setting in Baltimore, MD. A participating provider accepts it as payment in full, and every figure below starts from it.

$275.31
Medicare's share

80% of the allowed amount, once the annual Part B deductible is met.

$220.25
Sequestration

The 2% cut to Medicare’s share. It never reduces the allowed amount or the patient’s coinsurance.

-$4.41
What Medicare pays

Medicare’s share after sequestration.

$215.84
Patient coinsurance

The remaining 20%. Medigap or Medicaid often covers it.

$55.06
Non-participating amount

What a provider who doesn’t participate in Medicare is allowed on an assigned claim: 95% of the allowed amount.

$261.54
Limiting charge

The most a non-participating provider can bill the patient on an unassigned claim: 115% of the non-participating amount.

$300.77
What is the non-participating amount and limiting charge for 42820 in Baltimore, MD?

A non-participating provider is paid $261.54—95% of the $275.31 participating fee schedule amount. On an unassigned claim the limiting charge caps what the patient can be billed at $300.77, which is 115% of the non-participating amount.

How much of the Baltimore, MD 42820 rate does Medicare actually pay?

Medicare pays 80% of the allowed amount ($220.25) once the annual Part B deductible is met, and the beneficiary owes 20% ($55.06). Sequestration reduces Medicare's share by about 2% ($4.41), leaving $215.84. Sequestration never changes the allowed amount itself, which is why it is shown separately here.

Who’s billing it in Baltimore, MD Copy link

The allowed amount depends on who bills the service: NPs and PAs get 85% of the fee schedule amount, social workers and counselors 75%. These are Baltimore, MD’s Q4 2026 amounts.

Allowed amount for 42820 by rendering provider, Baltimore, MD
Billed by Office (non-facility) Facility
Physician (MD/DO) 100% The full fee schedule amount. Open in calculator $275.31 $275.31
Physician assisting at surgery (-80, -81, -82) 16% 16% of the fee schedule amount, but only if documentation shows the assistant was medically necessary. Source: Pub. 100-04 ch. 12 §20.4.3 Open in calculator $44.05 $44.05

There’s no CMS utilization data on file for 42820, so only the physician amounts are shown. Each percentage applies before the 80/20 split and sequestration.

Contract rates and comparisons Copy link

Contracted rate: % of Medicare in Baltimore, MD Copy link

Commercial contracts are often written as a percentage of the Medicare fee schedule. The part that gets misread is which Medicare amount: a contract benchmarked to the fee schedule prices off this locality's allowed amount—$275.31 in the office (non-facility) setting—not the $260.86 national baseline.

Opens the calculator set to Baltimore, MD and your selected setting, where you can also compare what a payer paid against the expected amount. See how to find your contract's actual percentage.

42820 in nearby payment localities Copy link

Payment localities in the same region as Baltimore, MD, nearest first. Each amount is that locality's own GPCI-adjusted Office (non-facility) figure for 42820. Neighboring localities often differ.

Payment locality Allowed · vs. this page

Percentages are against Baltimore, MD. Every payment locality nationwide is on the CPT 42820 rate map.

Other codes priced in Baltimore, MD Copy link

Office (non-facility) allowed amounts in this same payment locality, Q4 2026.

Other curated codes and their allowed amounts in Baltimore, MD
Code and service Allowed vs. national
99213 Routine Follow-Up Office Visit $100.16 +5.2%
99214 Long Follow-Up Office Visit $142.62 +5.2%
66984 Cataract Surgery $485.68 +5.0%
92014 Full Eye Exam, Returning Patient $134.06 +5.3%
99204 Long New Patient Office Visit $186.67 +5.2%
99215 Longest Follow-Up Office Visit $202.25 +5.1%
97110 Physical Therapy Exercises $30.38 +4.5%
99203 New Patient Office Visit $123.98 +5.5%
93000 Heart Tracing $16.27 +5.9%
93306 Heart Ultrasound $208.83 +6.2%
77067 Screening Mammogram $134.34 +6.4%
27447 Knee Replacement $1,229.62 +6.1%

Source & method Copy link

Computed from the CMS Medicare Physician Fee Schedule Q4 2026 release: this code's RVUs from the relative value file, multiplied by payment locality 12302-01's GPCIs, then by the 2026 conversion factor of $33.4009. ZIP coverage from the CMS ZIP-to-locality crosswalk, Q4 2026 release. Past releases are never edited, so an amount for an earlier quarter always matches what CMS published for it. Coverage and coding correctness are outside this calculation.

Physician relative value file (Q4 2026) · rvu26d-updated-08-26-2026.zip (PPRRVU2026_Oct_nonQPP.csv row 5,079)
Geographic practice cost indices (Q4 2026) · rvu26d-updated-08-26-2026.zip (GPCI2026.csv row 60)
ZIP code to carrier locality crosswalk (Q4 2026) · zip-code-carrier-locality-file-updated-08-13-2026.zip (ZIP5_OCT2026.txt)

Working a claim with an earlier date of service? The calculator prices 42820 in Baltimore, MD against the release in effect on that date. Dates of service this quarter don't need an account; earlier dates need a free account.

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