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CPT code 64491: Facet injection, cervical/thoracic second level2026 Medicare rate & RVUs in Puerto Rico

Reports an additional cervical or thoracic facet-joint injection level performed with a primary-level procedure during the same treatment session.

CMS RVU26DEffective Oct 1, 2026One payment locality134K Medicare services in 2024

In Puerto Rico, Medicare pays $102.48 for 64491 in the office and $50.82 when it’s performed in a hospital or facility.

$102.48Office (non-facility)
$50.82Hospital or facility
+0.6%vs the national office rate ($101.87)

Check a contract rate as a % of Medicare · 64491 nationwide

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

We’ll open 64491 for the payment locality that covers the ZIP.

On this page 11 sections
  1. Rate in Puerto Rico
  2. What 64491 covers
  3. Compared with other areas
  4. Rate map
  5. How it’s calculated
  6. Payment rules
  7. Related codes
  8. Rate history
  9. Where it applies
  10. Billing questions
  11. Sources

What 64491 covers

This add-on code covers injection at a second cervical or thoracic paravertebral facet-joint level, or the nerves supplying that joint, commonly for diagnostic evaluation or treatment of suspected facet-mediated neck or upper-back pain. Pain-management physicians and other qualified practitioners perform the procedure, often using imaging to guide needle placement. The code is specific to the cervical or thoracic region; lumbar facet levels are reported from a separate code family.

Report 64491 with the primary-level code 64490 when a second level is treated; it is not reported by itself. Documentation should identify the spinal region, each treated level and side, and the procedure performed. Imaging guidance is included in the facet-injection service. CMS treats 64491 as an add-on paid within the primary procedure’s global period. For a bilateral procedure reported with modifier 50, CMS pays 150% of the applicable amount.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

How Puerto Rico compares for 64491

Across 109 of 109 payment localities, the office rate for 64491 runs from $91.57 in Arkansas to $131.04 in San Benito County, CA. Puerto Rico pays $102.48. The RVUs are the same everywhere; the geographic indexes change the dollars.

64491 in Puerto Rico vs other payment areas
  1. Puerto Rico · this page$102.48
  2. Los Angeles, CA · California$113.25+$10.77
  3. Washington, DC area · District of Columbia$115.09+$12.61
  4. Miami, FL · Florida$109.97+$7.49
  5. Chicago, IL · Illinois$107.20+$4.72
  6. Manhattan, NY · New York$116.24+$13.76
  7. Alaska · Alaska$123.02+$20.54

Other areas in Puerto Rico first, then benchmark localities. Bars start at $0.

Every other payment area

64491 in every other Medicare payment locality
Payment localityOfficeFacility
AlabamaAlabama$92.72$48.01
ArkansasArkansas$91.57$47.67
ArizonaArizona$99.47$49.95
Bakersfield, CACalifornia$106.96$50.95
Chico, CACalifornia$106.61$50.60
El Centro, CACalifornia$106.63$50.62
Fresno, CACalifornia$106.61$50.60
Hanford, CACalifornia$106.61$50.60

64491 rates by state

Office rate range in each state. Select a state to see its payment localities.

MEWIVTNHMTNDMNMINYMARIWAIDWYSDIAILINOHPANJCTORNVUTCONEMOKYWVVAMDDECAAZNMKSOKARTNNCSCDCTXLAMSALGAFLAKHI

Explore a state

Local rates. Clear comparisons.

Hover or focus a tile to see its rate range. Select it to open the state’s fee schedule.

$91.57

$123.02

Color shows the midpoint of each state’s locality range.

View every state and territory as a table
64491 office rate range by state
State / territoryOffice rate rangeLocalities
AK$123.021
AL$92.721
AR$91.571
AZ$99.471
CA$106.61–$131.0429
CO$105.391
CT$108.051
DC$115.091
DE$100.961
FL$101.06–$109.973
GA$96.05–$103.692
GU$108.611
HI$108.611
IA$94.521
ID$95.101
IL$98.68–$107.204
IN$95.571
KS$94.251
KY$94.851
LA$94.77–$98.812
MA$104.93–$114.742
MD$102.67–$115.093
ME$95.65–$99.972
MI$97.09–$102.282
MN$101.041
MO$93.43–$98.983
MS$92.511
MT$101.871
NC$96.501
ND$99.691
NE$94.931
NH$103.891
NJ$109.30–$114.172
NM$97.591
NV$101.321
NY$97.76–$118.865
OH$96.641
OK$94.581
OR$100.54–$108.252
PA$96.71–$105.742
PR$102.481
RI$104.191
SC$96.731
SD$99.431
TN$94.671
TX$96.17–$105.048
UT$97.871
VA$99.76–$115.092
VI$102.481
VT$99.451
WA$104.69–$116.812
WI$96.791
WV$95.541
WY$100.921

See 64491 in every payment locality

How the 64491 rate is calculated

Each of 64491’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

How the rate is built · 64491

RVUs × geographic indexes × conversion factor

Office or facility?

Work1.13

1.13 RVUs× 1.000 GPCI

Practice expense1.81

1.81 RVUs× 1.000 GPCI

Malpractice0.11

0.11 RVUs× 1.000 GPCI

Adjusted RVUs

3.0500

Conversion factor

$33.4009

Medicare rate

$101.87

Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.

The exact Puerto Rico inputs and CMS source lines

PPRRVU2026_Oct_nonQPP.csv

7,135

Code
64491
Physician work
1.13
Practice expense
1.81
Malpractice
0.11

GPCI2026.csv

91

Locality
Puerto Rico
Physician work
1.000
Practice expense
1.011
Malpractice
0.985
Office calculation for 64491 in Puerto Rico
ComponentRVULocality factorAdjusted
Physician work1.13× 1.0001.1300
Practice expense1.81× 1.0111.8299
Malpractice0.11× 0.9850.1084
Total RVUs3.0683
Conversion factor× 33.4009

Office rate, Puerto Rico$102.48

Office: (1.13 × 1 + 1.81 × 1.011 + 0.11 × 0.985) × $33.4009 = $102.48

Facility: (1.13 × 1 + 0.28 × 1.011 + 0.11 × 0.985) × $33.4009 = $50.82

Open 64491 in the RVU calculator

Payment rules and modifiers for 64491

The CMS indicators that decide how 64491 is paid alongside other services.

CMS payment indicators · 64491

Facet injection, cervical/thoracic second level

RuleCMS valueWhat it means
Global periodZZZAdd-on code: falls within the primary procedure’s global period.
Multiple procedures0No multiple-procedure reduction.
Bilateral (modifier 50)1Bilateral with modifier 50 pays 150% of the fee schedule amount.
Assistant at surgery (80/81/82/AS)2Paid.
Co-surgeons (62)0Not permitted.
Team surgery (66)0Not permitted.
Professional/technical0Physician service: no professional/technical split.

What modifiers do to the payment

Modifier 50 · payment effect

With and without the modifier

64491 without 50 · national office

$101.87

Facet injection, cervical/thoracic second level

64491-50 · Bilateral: 150%

$152.81

Both sides on one line with modifier 50 are paid at 150% of the fee schedule amount (subject to multiple-procedure rules with other procedures).

When to use modifier 50

Codes related to 64491

Related codes aren’t interchangeable: bill the code that matches the service performed.

Codes related to 64491
CodeHow it relatesOffice range, Puerto Rico
Often billed with
64490Facet injection, cervical or thoracic, one levelPrimary-level cervical or thoracic facet injection reported with this add-on.$206.54
Same family
64492Facet injection, third cervical/thoracic levelCervical or thoracic additional-level code for a third treated level.$102.84
64493Facet joint injection, lumbar or sacral, one levelPrimary-level facet injection code for the lumbar or sacral region.$191.81
64494Facet joint injection, lumbar/sacral, second levelSecond-level additional code for lumbar or sacral facet injections.$96.49

How 64491 has changed in Puerto Rico

64491 · Office / nonfacility

$102.48

Effective 2026-10-01

The base rate is $7.41 higher than on 2025-10-01, moving from $95.07 to $102.48 (7.8%).

It is unchanged from the immediately preceding available release, effective 2026-07-01.

Base rate by release · bars start at $0 · select a bar to compare

One bar per available release, ordered by effective date. Missing rates remain gaps. These comparisons hold the code, setting and locality identifiers constant; they do not isolate which policy or input caused a change.

What changed, release by release

  1. January 1, 2026

    RVU26A

    $95.07changed to$102.48

    • Conversion factor 32.3465 changed to 33.4009
    • Work RVU 1.16 changed to 1.13
    • Practice expense RVU 1.64 changed to 1.81
    • Malpractice RVU 0.13 changed to 0.11
    • Practice expense GPCI 1.007 changed to 1.011
    • Malpractice GPCI 0.982 changed to 0.985

    Held through RVU26B, RVU26C, RVU26D.

  2. January 1, 2025

    RVU25A

    $97.51changed to$95.07

    • Conversion factor 33.2875 changed to 32.3465
    • Malpractice RVU 0.12 changed to 0.13

    Held through RVU25B, RVU25C, RVU25D.

  3. March 9, 2024

    RVU24AR

    $95.92changed to$97.51

    • Conversion factor 32.7442 changed to 33.2875

    Held through RVU24B, RVU24C, RVU24D.

  4. January 1, 2024

    RVU24A

    $98.31changed to$95.92

    • Conversion factor 33.8872 changed to 32.7442
    • Practice expense RVU 1.61 changed to 1.64
    • Practice expense GPCI 1.008 changed to 1.007
    • Malpractice GPCI 0.984 changed to 0.982

  5. October 1, 2023

    RVU23D

    $97.93changed to$98.31

    • Practice expense GPCI 1.000 changed to 1.008
    • Malpractice GPCI 1.000 changed to 0.984

  6. January 1, 2023

    RVU23A

    $99.71changed to$97.93

    • Conversion factor 34.6062 changed to 33.8872
    • Practice expense RVU 1.60 changed to 1.61
    • Malpractice RVU 0.11 changed to 0.12
    • Practice expense GPCI 1.008 changed to 1.000
    • Malpractice GPCI 0.986 changed to 1.000

    Held through RVU23B, RVU23C.

  7. January 1, 2022

    RVU22A

    $101.22changed to$99.71

    • Conversion factor 34.8931 changed to 34.6062
    • Malpractice RVU 0.13 changed to 0.11

    Held through RVU22B, RVU22C, RVU22D.

  8. January 1, 2021

    RVU21A

    $98.53changed to$101.22

    • Conversion factor 36.0896 changed to 34.8931
    • Practice expense RVU 1.45 changed to 1.60
    • Malpractice RVU 0.11 changed to 0.13
    • Malpractice GPCI 0.988 changed to 0.986

    Held through RVU21B, RVU21C, RVU21D.

  9. January 1, 2020

    RVU20A

    $96.91changed to$98.53

    • Conversion factor 36.0391 changed to 36.0896
    • Practice expense RVU 1.42 changed to 1.45
    • Malpractice RVU 0.10 changed to 0.11
    • Practice expense GPCI 1.007 changed to 1.008
    • Malpractice GPCI 0.990 changed to 0.988

    Held through RVU20B, RVU20C, RVU20D.

  10. January 1, 2019

    RVU19A

    $95.71changed to$96.91

    • Conversion factor 35.9996 changed to 36.0391
    • Practice expense RVU 1.39 changed to 1.42

    Held through RVU19B, RVU19C, RVU19D.

  11. January 1, 2018

    RVU18AR1

    $86.64changed to$95.71

    • Conversion factor 35.8887 changed to 35.9996
    • Practice expense GPCI 0.856 changed to 1.007
    • Malpractice GPCI 0.642 changed to 0.990

    Held through RVU18B, RVU18C, RVU18D.

  12. January 1, 2017

    RVU17A

    $78.43changed to$86.64

    • Conversion factor 35.8043 changed to 35.8887
    • Practice expense RVU 1.42 changed to 1.39
    • Practice expense GPCI 0.705 changed to 0.856
    • Malpractice GPCI 0.293 changed to 0.642

    Held through RVU17B, RVU17C, RVU17D.

  13. January 1, 2016

    RVU16A

    $78.71changed to$78.43

    • Conversion factor 35.9335 changed to 35.8043

    Held through RVU16B, RVU16C, RVU16D.

  14. July 1, 2015

    RVU15C

    $78.32changed to$78.71

    • Conversion factor 35.7547 changed to 35.9335

    Held through RVU15D.

  15. January 1, 2015

    RVU15A

    $77.82changed to$78.32

    • Conversion factor 35.8228 changed to 35.7547
    • Malpractice RVU 0.11 changed to 0.10
    • Practice expense GPCI 0.692 changed to 0.705
    • Malpractice GPCI 0.271 changed to 0.293

    Held through RVU15B.

  16. January 1, 2014

    RVU14A

    $77.54changed to$77.82

    • Conversion factor 34.0230 changed to 35.8228
    • Practice expense RVU 1.61 changed to 1.42
    • Practice expense GPCI 0.678 changed to 0.692
    • Malpractice GPCI 0.249 changed to 0.271

    Held through RVU14B, RVU14C, RVU14D.

  17. January 1, 2013

    RVU13AR

    Earliest loaded release: $77.54

    Held through RVU13B, RVU13C, RVU13D.

Rates in every CMS release
Effective fromOfficeFacilityCMS release
2026-10-01$102.48$50.82RVU26D
2026-07-01$102.48$50.82RVU26C
2026-04-01$102.48$50.82RVU26B
2026-01-01$102.48$50.82RVU26A
2025-10-01$95.07$57.61RVU25D
2025-07-01$95.07$57.61RVU25C
2025-04-01$95.07$57.61RVU25B
2025-01-01$95.07$57.61RVU25A
2024-10-01$97.51$58.63RVU24D
2024-07-01$97.51$58.63RVU24C
2024-04-01$97.51$58.63RVU24B
2024-03-09$97.51$58.63RVU24AR
2024-01-01$95.92$57.67RVU24A
2023-10-01$98.31$59.36RVU23D
2023-07-01$97.93$59.30RVU23C
2023-04-01$97.93$59.30RVU23B
2023-01-01$97.93$59.30RVU23A
2022-10-01$99.71$60.29RVU22D
2022-07-01$99.71$60.29RVU22C
2022-04-01$99.71$60.29RVU22B
2022-01-01$99.71$60.29RVU22A
2021-10-01$101.22$61.48RVU21D
2021-07-01$101.22$61.48RVU21C
2021-04-01$101.22$61.48RVU21B
2021-01-01$101.22$61.48RVU21A
2020-10-01$98.53$62.52RVU20D
2020-07-01$98.53$62.52RVU20C
2020-04-01$98.53$62.52RVU20B
2020-01-01$98.53$62.52RVU20A
2019-10-01$96.91$62.07RVU19D
2019-07-01$96.91$62.07RVU19C
2019-04-01$96.91$62.07RVU19B
2019-01-01$96.91$62.07RVU19A
2018-10-01$95.71$62.36RVU18D
2018-07-01$95.71$62.36RVU18C
2018-04-01$95.71$62.36RVU18B
2018-01-01$95.71$62.36RVU18AR1
2017-10-01$86.64$58.37RVU17D
2017-07-01$86.64$58.37RVU17C
2017-04-01$86.64$58.37RVU17B
2017-01-01$86.64$58.37RVU17A
2016-10-01$78.43$54.70RVU16D
2016-07-01$78.43$54.70RVU16C
2016-04-01$78.43$54.70RVU16B
2016-01-01$78.43$54.70RVU16A
2015-10-01$78.71$54.90RVU15D
2015-07-01$78.71$54.90RVU15C
2015-04-01$78.32$54.62RVU15B
2015-01-01$78.32$54.62RVU15A
2014-10-01$77.82$54.77RVU14D
2014-07-01$77.82$54.77RVU14C
2014-04-01$77.82$54.77RVU14B
2014-01-01$77.82$54.77RVU14A
2013-10-01$77.54$52.86RVU13D
2013-07-01$77.54$52.86RVU13C
2013-04-01$77.54$52.86RVU13B
2013-01-01$77.54$52.86RVU13AR

Price 64491 for an earlier date of service

Where the Puerto Rico rate applies

Puerto Rico is a Medicare payment area, not a city. Our Census mapping connects it to 292 cities and communities in Puerto Rico. Some span more than one payment area; confirm with the service ZIP.

  • Aceitunas
  • Adjuntas
  • Aguada
  • Aguadilla
  • Aguas Buenas
  • Aguas Claras
  • Aguilita
  • Aibonito

Browse all communities in Puerto Rico

64491 billing questions

When is 64491 reported with 64490?

Report 64491 for a second cervical or thoracic facet-joint level in the same session as the primary-level service reported with 64490. It cannot be reported alone.

How does 64491 differ from 64490?

64490 represents the primary level; 64491 represents the additional second level. The documentation should show that a distinct second level was treated.

Can 64491 be reported with 64492?

When a third cervical or thoracic level is treated, 64492 is the additional-level code for that level, alongside the primary-level service. The record should support each treated level.

How is bilateral treatment handled?

For a bilateral procedure, CMS pays 150% when modifier 50 is used. Document the treated side or sides and levels.

Is imaging guidance separately reported?

Imaging guidance is included in the facet-injection service. Do not separately report guidance for the injection represented by 64491.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Show the CMS file lines behind this rate
RVUs for 64491PPRRVU2026_Oct_nonQPP.csv, line 7,135 (RVU26D)
Geographic factors for Puerto RicoGPCI2026.csv, line 91 (RVU26D)

Open CMS sourceHow we calculate rates

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