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CPT code 78650: CSF leak imaging, leak detection and localization2026 Medicare rate & RVUs in Puerto Rico

Reports nuclear medicine imaging performed to detect and localize a suspected cerebrospinal fluid leak, such as leakage from the cranial or spinal CSF space.

CMS RVU26DEffective Oct 1, 2026One payment locality27 Medicare services in 2024

In Puerto Rico, Medicare pays $247.58 for 78650 in the office.

$247.58Office (non-facility)
Not available in this settingHospital or facility
+1.0%vs the national office rate ($245.16)

Check a contract rate as a % of Medicare · 78650 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 78650 for the payment locality that covers the ZIP.

On this page 11 sections
  1. Rate in Puerto Rico
  2. What 78650 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 78650 covers

This nuclear medicine study traces cerebrospinal fluid to identify and localize a suspected leak. It may be used when a patient has signs of CSF leakage, including persistent clear drainage after head or spinal surgery or trauma. A radiologist or nuclear medicine physician interprets the resulting images; the technical service involves the imaging equipment and staff. The study is generally performed in a hospital or imaging department equipped for nuclear medicine procedures.

Select 78650 when the diagnostic purpose is finding and locating a CSF leak, rather than evaluating general CSF circulation, ventricular anatomy, or shunt function. Documentation should identify the suspected leak, the imaging procedure performed, and the physician’s interpretation and findings. Medicare recognizes professional and technical components: report modifier 26 for interpretation, modifier TC for equipment and staff, or no modifier for the global service when one entity provides both.

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 78650

Across 109 of 109 payment localities, the office rate for 78650 runs from $212.57 in Arkansas to $344.86 in San Benito County, CA. Puerto Rico pays $247.58. The RVUs are the same everywhere; the geographic indexes change the dollars.

78650 in Puerto Rico vs other payment areas
  1. Puerto Rico · this page$247.58
  2. Los Angeles, CA · California$286.02+$38.44
  3. Washington, DC area · District of Columbia$286.21+$38.63
  4. Miami, FL · Florida$257.89+$10.31
  5. Chicago, IL · Illinois$249.44+$1.86
  6. Manhattan, NY · New York$283.94+$36.36
  7. Alaska · Alaska$268.47+$20.89

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

Every other payment area

78650 in every other Medicare payment locality
Payment localityOfficeFacility
AlabamaAlabama$216.26—
ArkansasArkansas$212.57—
ArizonaArizona$237.91—
Bakersfield, CACalifornia$266.04—
Chico, CACalifornia$265.83—
El Centro, CACalifornia$265.84—
Fresno, CACalifornia$265.83—
Hanford, CACalifornia$265.83—

78650 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.

$212.57

$305.35

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

View every state and territory as a table
78650 office rate range by state
State / territoryOffice rate rangeLocalities
AK$268.471
AL$216.261
AR$212.571
AZ$237.911
CA$265.83–$344.8629
CO$259.171
CT$263.231
DC$286.211
DE$242.351
FL$236.52–$257.893
GA$221.51–$249.262
GU$274.751
HI$274.751
IA$224.791
ID$226.081
IL$227.07–$253.134
IN$227.671
KS$222.581
KY$220.201
LA$219.41–$232.322
MA$256.83–$289.002
MD$247.85–$286.213
ME$226.43–$242.292
MI$226.05–$238.962
MN$249.991
MO$214.31–$234.463
MS$213.541
MT$245.161
NC$229.371
ND$243.771
NE$226.531
NH$254.021
NJ$266.70–$282.262
NM$227.111
NV$245.001
NY$233.31–$290.605
OH$225.771
OK$220.771
OR$243.58–$269.652
PA$226.74–$255.122
PR$247.581
RI$252.651
SC$227.851
SD$243.611
TN$223.781
TX$224.92–$257.888
UT$231.541
VA$240.68–$286.212
VI$247.581
VT$241.781
WA$256.69–$296.372
WI$234.171
WV$216.941
WY$244.551

See 78650 in every payment locality

How the 78650 rate is calculated

Each of 78650’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 · 78650

RVUs × geographic indexes × conversion factor

Office or facility?

Work0.59

0.59 RVUs× 1.000 GPCI

Practice expense6.68

6.68 RVUs× 1.000 GPCI

Malpractice0.07

0.07 RVUs× 1.000 GPCI

Adjusted RVUs

7.3400

Conversion factor

$33.4009

Medicare rate

$245.16

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

9,473

Code
78650
Physician work
0.59
Practice expense
6.68
Malpractice
0.07

GPCI2026.csv

91

Locality
Puerto Rico
Physician work
1.000
Practice expense
1.011
Malpractice
0.985
Office calculation for 78650 in Puerto Rico
ComponentRVULocality factorAdjusted
Physician work0.59× 1.0000.5900
Practice expense6.68× 1.0116.7535
Malpractice0.07× 0.9850.0690
Total RVUs7.4124
Conversion factor× 33.4009

Office rate, Puerto Rico$247.58

Office: (0.59 × 1 + 6.68 × 1.011 + 0.07 × 0.985) × $33.4009 = $247.58

Open 78650 in the RVU calculator

Payment rules and modifiers for 78650

The CMS indicators that decide how 78650 is paid alongside other services.

CMS payment indicators · 78650

CSF leak imaging, leak detection and localization

RuleCMS valueWhat it means
Global periodXXXThe global surgery concept doesn’t apply.
Multiple procedures0No multiple-procedure reduction.
Bilateral (modifier 50)0The 150% bilateral adjustment doesn’t apply.
Assistant at surgery (80/81/82/AS)0Not paid without supporting documentation.
Co-surgeons (62)0Not permitted.
Team surgery (66)0Not permitted.
Professional/technical1Diagnostic test with separate professional (26) and technical (TC) components.

What modifiers do to the payment

Modifier 26 · payment effect

With and without the modifier

78650 without 26 · national office

$245.16

CSF leak imaging, leak detection and localization

78650-26 · Professional component

$23.71

Pays only the interpretation and report.

When to use modifier 26

Codes related to 78650

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

Codes related to 78650
CodeHow it relatesOffice range, Puerto Rico
Used instead
78630CSF scan, cisternographyCisternography is selected for a CSF cisternographic study rather than targeted leak localization.$297.51
78645CSF shunt study, shunt patency assessmentEvaluates CSF shunt function rather than locating a CSF leak.$288.11
78635CSF imaging, ventricular flow studyRadiopharmaceutical ventriculography evaluates the ventricular CSF pathway, not a suspected leak.$297.55

How 78650 has changed in Puerto Rico

78650 · Office / nonfacility

$247.58

Effective 2026-10-01

The base rate is $10.96 higher than on 2025-10-01, moving from $236.62 to $247.58 (4.6%).

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

    $236.62changed to$247.58

    • Conversion factor 32.3465 changed to 33.4009
    • Work RVU 0.61 changed to 0.59
    • Practice expense RVU 6.60 changed to 6.68
    • Malpractice RVU 0.06 changed to 0.07
    • 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

    $248.86changed to$236.62

    • Conversion factor 33.2875 changed to 32.3465
    • Practice expense RVU 6.75 changed to 6.60
    • Malpractice RVU 0.07 changed to 0.06

    Held through RVU25B, RVU25C, RVU25D.

  3. March 9, 2024

    RVU24AR

    $244.80changed to$248.86

    • Conversion factor 32.7442 changed to 33.2875

    Held through RVU24B, RVU24C, RVU24D.

  4. January 1, 2024

    RVU24A

    $258.03changed to$244.80

    • Conversion factor 33.8872 changed to 32.7442
    • Practice expense RVU 6.90 changed to 6.75
    • Malpractice RVU 0.05 changed to 0.07
    • Practice expense GPCI 1.008 changed to 1.007
    • Malpractice GPCI 0.984 changed to 0.982

  5. October 1, 2023

    RVU23D

    $256.19changed to$258.03

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

  6. January 1, 2023

    RVU23A

    $273.97changed to$256.19

    • Conversion factor 34.6062 changed to 33.8872
    • Practice expense RVU 7.19 changed to 6.90
    • Malpractice RVU 0.06 changed to 0.05
    • 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

    $287.14changed to$273.97

    • Conversion factor 34.8931 changed to 34.6062
    • Practice expense RVU 7.50 changed to 7.19

    Held through RVU22B, RVU22C, RVU22D.

  8. January 1, 2021

    RVU21A

    $286.81changed to$287.14

    • Conversion factor 36.0896 changed to 34.8931
    • Practice expense RVU 7.22 changed to 7.50
    • Malpractice GPCI 0.988 changed to 0.986

    Held through RVU21B, RVU21C, RVU21D.

  9. January 1, 2020

    RVU20A

    $286.15changed to$286.81

    • Conversion factor 36.0391 changed to 36.0896
    • Practice expense RVU 7.23 changed to 7.22
    • Malpractice RVU 0.05 changed to 0.06
    • 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

    $289.47changed to$286.15

    • Conversion factor 35.9996 changed to 36.0391
    • Practice expense RVU 7.33 changed to 7.23

    Held through RVU19B, RVU19C, RVU19D.

  11. January 1, 2018

    RVU18AR1

    $300.30changed to$289.47

    • Conversion factor 35.8887 changed to 35.9996
    • Practice expense RVU 9.01 changed to 7.33
    • Malpractice RVU 0.07 changed to 0.05
    • 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

    $247.73changed to$300.30

    • Conversion factor 35.8043 changed to 35.8887
    • Practice expense RVU 8.92 changed to 9.01
    • 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

    $251.01changed to$247.73

    • Conversion factor 35.9335 changed to 35.8043
    • Practice expense RVU 9.01 changed to 8.92
    • Malpractice RVU 0.08 changed to 0.07

    Held through RVU16B, RVU16C, RVU16D.

  14. July 1, 2015

    RVU15C

    $249.76changed to$251.01

    • Conversion factor 35.7547 changed to 35.9335

    Held through RVU15D.

  15. January 1, 2015

    RVU15A

    $243.16changed to$249.76

    • Conversion factor 35.8228 changed to 35.7547
    • Practice expense RVU 8.90 changed to 9.01
    • Malpractice RVU 0.07 changed to 0.08
    • 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

    $238.87changed to$243.16

    • Conversion factor 34.0230 changed to 35.8228
    • Practice expense RVU 9.43 changed to 8.90
    • 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: $238.87

    Held through RVU13B, RVU13C, RVU13D.

Rates in every CMS release
Effective fromOfficeFacilityCMS release
2026-10-01$247.58Not available in this settingRVU26D
2026-07-01$247.58Not available in this settingRVU26C
2026-04-01$247.58Not available in this settingRVU26B
2026-01-01$247.58Not available in this settingRVU26A
2025-10-01$236.62Not available in this settingRVU25D
2025-07-01$236.62Not available in this settingRVU25C
2025-04-01$236.62Not available in this settingRVU25B
2025-01-01$236.62Not available in this settingRVU25A
2024-10-01$248.86Not available in this settingRVU24D
2024-07-01$248.86Not available in this settingRVU24C
2024-04-01$248.86Not available in this settingRVU24B
2024-03-09$248.86Not available in this settingRVU24AR
2024-01-01$244.80Not available in this settingRVU24A
2023-10-01$258.03Not available in this settingRVU23D
2023-07-01$256.19Not available in this settingRVU23C
2023-04-01$256.19Not available in this settingRVU23B
2023-01-01$256.19Not available in this settingRVU23A
2022-10-01$273.97Not available in this settingRVU22D
2022-07-01$273.97Not available in this settingRVU22C
2022-04-01$273.97Not available in this settingRVU22B
2022-01-01$273.97Not available in this settingRVU22A
2021-10-01$287.14Not available in this settingRVU21D
2021-07-01$287.14Not available in this settingRVU21C
2021-04-01$287.14Not available in this settingRVU21B
2021-01-01$287.14Not available in this settingRVU21A
2020-10-01$286.81Not available in this settingRVU20D
2020-07-01$286.81Not available in this settingRVU20C
2020-04-01$286.81Not available in this settingRVU20B
2020-01-01$286.81Not available in this settingRVU20A
2019-10-01$286.15Not available in this settingRVU19D
2019-07-01$286.15Not available in this settingRVU19C
2019-04-01$286.15Not available in this settingRVU19B
2019-01-01$286.15Not available in this settingRVU19A
2018-10-01$289.47Not available in this settingRVU18D
2018-07-01$289.47Not available in this settingRVU18C
2018-04-01$289.47Not available in this settingRVU18B
2018-01-01$289.47Not available in this settingRVU18AR1
2017-10-01$300.30Not available in this settingRVU17D
2017-07-01$300.30Not available in this settingRVU17C
2017-04-01$300.30Not available in this settingRVU17B
2017-01-01$300.30Not available in this settingRVU17A
2016-10-01$247.73Not available in this settingRVU16D
2016-07-01$247.73Not available in this settingRVU16C
2016-04-01$247.73Not available in this settingRVU16B
2016-01-01$247.73Not available in this settingRVU16A
2015-10-01$251.01Not available in this settingRVU15D
2015-07-01$251.01Not available in this settingRVU15C
2015-04-01$249.76Not available in this settingRVU15B
2015-01-01$249.76Not available in this settingRVU15A
2014-10-01$243.16Not available in this settingRVU14D
2014-07-01$243.16Not available in this settingRVU14C
2014-04-01$243.16Not available in this settingRVU14B
2014-01-01$243.16Not available in this settingRVU14A
2013-10-01$238.87Not available in this settingRVU13D
2013-07-01$238.87Not available in this settingRVU13C
2013-04-01$238.87Not available in this settingRVU13B
2013-01-01$238.87Not available in this settingRVU13AR

Price 78650 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

78650 billing questions

When should 78650 be chosen over 78630?

Use 78650 when the study is directed at detecting and localizing a CSF leak. Code 78630 describes cisternography when the purpose is a CSF cisternographic study rather than targeted leak localization.

How are the professional and technical services reported?

Report modifier 26 for the physician’s interpretation and modifier TC for the technical service. Report the code without a modifier when billing the global service.

What documentation supports 78650?

Document the clinical suspicion of a CSF leak, the imaging performed to locate it, and the interpreting physician’s findings. The record should make clear that leak detection or localization was the study’s purpose.

Is 78650 the code for evaluating a CSF shunt?

No. 78650 addresses suspected CSF leakage; 78645 is for evaluation of a CSF shunt.

Can the professional and technical components be billed separately?

Yes. Medicare identifies separately priced professional and technical components for this diagnostic test, reported with modifiers 26 and TC, respectively.

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 78650PPRRVU2026_Oct_nonQPP.csv, line 9,473 (RVU26D)
Geographic factors for Puerto RicoGPCI2026.csv, line 91 (RVU26D)

Open CMS sourceHow we calculate rates

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