CPT / HCPCS code · 2026 CMS data · Verified 2026-08-31
CPT 42225 RVU and Medicare Payment (2026)
Reconstruct cleft palate — 9.53 work RVU, about $969.29 non-facility Medicare payment at the 2026 conversion factor.
- Work RVU
- 9.53
- PE RVU (non-facility)
- 17.73
- PE RVU (facility)
- 17.73
- MP RVU
- 1.76
- Office payment
- $969.29
- Facility payment
- $969.29
How the payment is calculated
Total RVU is work plus practice expense plus malpractice, each adjusted by its GPCI factor, then multiplied by the conversion factor. For 42225 in a non-facility setting with national GPCI: (9.53 + 17.73 + 1.76) × $33.4009 ≈ $969.29. The same code in a facility setting pays about $969.29 because facility PE RVU (17.73) replaces office PE RVU.
What changes by locality
GPCI moves 42225 non-facility payment from $857.28 to $1,238.78 across CMS localities — from Arkansas to San Jose-sunnyvale-santa Clara (san Benito Cnty). Check your exact locality in the GPCI calculator rather than using a state average.
Related codes
Checking a different code or locality? Open the full RVU calculator to run any of the 7,790 CPT/HCPCS codes with your own GPCI factors.
Frequently asked questions
What is the 2026 work RVU for CPT 42225?
9.53. Work RVU measures physician time, skill, and intensity — it does not change by setting or locality. Total payment adds practice expense and malpractice RVUs plus the conversion factor.
How much does Medicare pay for CPT 42225 in 2026?
About $969.29 non-facility ($969.29 facility) at national GPCI with the 2026 $33.4009 conversion factor. Your locality GPCI moves the number — see the range above.
Does the work RVU change between office and facility?
No. Work RVU (9.53) and malpractice RVU stay fixed; only practice expense changes (17.73 office vs 17.73 facility). That is the entire office-vs-facility payment gap.