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CMS RVU26D · Effective 2026-10-01

42804 in Chico

Office / nonfacility

$229.43

Base rate per service

Facility setting

$117.04

Base rate per service

Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.

Otolaryngology

About 42804: Nasopharyngeal lesion biopsy

Biopsy of a lesion or abnormal tissue in the nasopharynx, reported when the clinician obtains tissue for diagnostic evaluation.

An otolaryngologist typically performs this service to obtain tissue from an abnormal area in the nasopharynx, the upper part of the throat behind the nasal cavity. The clinician reaches the site through the nose or another documented route and removes a specimen for diagnostic evaluation. The procedure may occur in an office or facility, depending on the lesion’s location, access, and the patient’s needs.

Report the code when the service is a nasopharyngeal biopsy, rather than a biopsy of the oropharynx or removal of a lesion. The record should identify the sampled site, describe the lesion or abnormal tissue, and document the biopsy performed. Related postoperative visits during the 10-day global period are included. When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard reduction. Modifier 50 is inappropriate. Assistant-at-surgery payment is restricted, and co-surgeons and team surgery are not permitted.

CMS billing rules for 42804

Global period
Minor procedure with a 10-day global period: related postoperative visits for 10 days are included.
Multiple procedures
Standard multiple procedure reduction: the highest-valued procedure is paid in full and others at 50% when performed in the same session.
Bilateral procedures
Bilateral adjustment does not apply; the descriptor or anatomy makes modifier 50 inappropriate.
Assistant at surgery
Statutory restriction: assistant at surgery is not paid.
Co-surgeons
Co-surgeons not permitted.
Team surgery
Team surgery not permitted.

Where the value comes from

  • Work RVU1.26 · 20%
  • Practice expense (office) RVU5.01 · 78%
  • Malpractice RVU0.18 · 3%

364

Medicare services in 2024 · #3814 by national volume

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.

42804 compared with similar codes

Office rates for Chico, from the same CMS release.

42800

Biopsy

Pharynx tissue sampling

$167.36

Choose 42804 for a nasopharyngeal specimen. Choose 42800 when the biopsy site is the oropharynx.

42806

Nasopharyngeal biopsy

Directly visualized tissue sampling

$255.26

This is a closely related nasopharyngeal biopsy code. Distinguish it from 42804 using the documented procedure and approach, not merely the site.

42808

Pharyngeal lesion treatment

Excision or destruction

$244.39

Use 42804 when tissue is sampled for diagnostic evaluation; 42808 describes excision of a pharyngeal lesion.

The same code, a different location

How does Chico compare?

In Bakersfield, the office rate for 42804 is $229.95—$0.52 higher than the $229.43 rate in Chico. Both use the same code, release and participation basis.

42804 across payment areas

Same release and payment basis · bars start at $0

  1. Chico · This locality

    $229.43

  2. Bakersfield

    $229.95

    $0.52 higher than Chico

  3. El Centro

    $229.46

    $0.03 higher than Chico

  4. Fresno

    $229.43

    The same base rate than Chico

  5. Hanford-Corcoran

    $229.43

    The same base rate than Chico

  6. Los Angeles-Long Beach-Anaheim (Los Angeles/Orange Cnty)

    $245.76

    $16.33 higher than Chico

  7. Madera

    $229.43

    The same base rate than Chico

Other payment areas listed in California appear first, followed by selected cross-country examples. The chart compares amounts, not distance.

Across 109 of 109 CMS payment localities with a supported office rate, 42804 ranges from $188.93 in Arkansas to $291.24 in San Jose-Sunnyvale-Santa Clara (San Benito Cnty). This is a geographic range, not an average.

The code’s RVUs stay the same in these comparisons. Geographic adjustments to work, practice expense and malpractice change the dollar amount. A city name alone may not identify the payment area for a service address.

Compare all 108 other payment areas

  • Merced

    California · 42804

    Office

    $229.43

    Facility

    $117.04

    The same base rate than Chico for the office setting.

  • Modesto

    California · 42804

    Office

    $229.43

    Facility

    $117.04

    The same base rate than Chico for the office setting.

  • Napa

    California · 42804

    Office

    $268.34

    Facility

    $133.19

    $38.91 higher than Chico for the office setting.

  • Oxnard-Thousand Oaks-Ventura

    California · 42804

    Office

    $244.80

    Facility

    $123.60

    $15.37 higher than Chico for the office setting.

  • Redding

    California · 42804

    Office

    $229.43

    Facility

    $117.04

    The same base rate than Chico for the office setting.

  • Rest Of California

    California · 42804

    Office

    $229.43

    Facility

    $117.04

    The same base rate than Chico for the office setting.

  • Riverside-San Bernardino-Ontario

    California · 42804

    Office

    $231.37

    Facility

    $118.99

    $1.94 higher than Chico for the office setting.

  • Sacramento-Roseville-Folsom

    California · 42804

    Office

    $241.44

    Facility

    $122.18

    $12.01 higher than Chico for the office setting.

  • Salinas

    California · 42804

    Office

    $240.56

    Facility

    $121.71

    $11.13 higher than Chico for the office setting.

  • San Diego-Chula Vista-Carlsbad

    California · 42804

    Office

    $246.74

    Facility

    $124.10

    $17.31 higher than Chico for the office setting.

  • San Francisco-Oakland-Berkeley (Marin Cnty)

    California · 42804

    Office

    $284.79

    Facility

    $140.21

    $55.36 higher than Chico for the office setting.

  • San Francisco-Oakland-Berkeley (San Francisco/San Mateo/Alameda/Contra Costa Cnty)

    California · 42804

    Office

    $284.59

    Facility

    $140.00

    $55.16 higher than Chico for the office setting.

  • San Jose-Sunnyvale-Santa Clara (San Benito Cnty)

    California · 42804

    Office

    $291.24

    Facility

    $143.38

    $61.81 higher than Chico for the office setting.

  • San Jose-Sunnyvale-Santa Clara (Santa Clara Cnty)

    California · 42804

    Office

    $290.40

    Facility

    $142.54

    $60.97 higher than Chico for the office setting.

  • San Luis Obispo-Paso Robles

    California · 42804

    Office

    $236.62

    Facility

    $119.83

    $7.19 higher than Chico for the office setting.

  • Santa Cruz-Watsonville

    California · 42804

    Office

    $249.51

    Facility

    $124.92

    $20.08 higher than Chico for the office setting.

  • Santa Maria-Santa Barbara

    California · 42804

    Office

    $241.60

    Facility

    $122.04

    $12.17 higher than Chico for the office setting.

  • Santa Rosa-Petaluma

    California · 42804

    Office

    $252.06

    Facility

    $126.14

    $22.63 higher than Chico for the office setting.

  • Stockton

    California · 42804

    Office

    $229.43

    Facility

    $117.04

    The same base rate than Chico for the office setting.

  • Vallejo

    California · 42804

    Office

    $268.05

    Facility

    $132.90

    $38.62 higher than Chico for the office setting.

  • Visalia

    California · 42804

    Office

    $229.43

    Facility

    $117.04

    The same base rate than Chico for the office setting.

  • Yuba City

    California · 42804

    Office

    $229.43

    Facility

    $117.04

    The same base rate than Chico for the office setting.

  • Dc + Md/Va Suburbs

    District of Columbia · 42804

    Office

    $248.17

    Facility

    $127.38

    $18.74 higher than Chico for the office setting.

  • Miami

    Florida · 42804

    Office

    $231.49

    Facility

    $124.74

    $2.06 higher than Chico for the office setting.

  • Chicago

    Illinois · 42804

    Office

    $224.35

    Facility

    $121.30

    $5.08 lower than Chico for the office setting.

  • Manhattan

    New York · 42804

    Office

    $248.76

    Facility

    $129.61

    $19.33 higher than Chico for the office setting.

  • Alaska*

    Alaska · 42804

    Office

    $244.66

    Facility

    $135.45

    $15.23 higher than Chico for the office setting.

  • Alabama

    Alabama · 42804

    Office

    $191.91

    Facility

    $102.19

    $37.52 lower than Chico for the office setting.

  • Arkansas

    Arkansas · 42804

    Office

    $188.93

    Facility

    $100.84

    $40.50 lower than Chico for the office setting.

  • Arizona

    Arizona · 42804

    Office

    $209.38

    Facility

    $110.02

    $20.05 lower than Chico for the office setting.

  • Colorado

    Colorado · 42804

    Office

    $225.33

    Facility

    $116.23

    $4.10 lower than Chico for the office setting.

  • Connecticut

    Connecticut · 42804

    Office

    $230.43

    Facility

    $119.99

    $1.00 higher than Chico for the office setting.

  • Delaware

    Delaware · 42804

    Office

    $213.03

    Facility

    $111.72

    $16.40 lower than Chico for the office setting.

  • Fort Lauderdale

    Florida · 42804

    Office

    $222.47

    Facility

    $118.60

    $6.96 lower than Chico for the office setting.

  • Rest Of Florida

    Florida · 42804

    Office

    $211.10

    Facility

    $113.07

    $18.33 lower than Chico for the office setting.

  • Atlanta

    Georgia · 42804

    Office

    $219.45

    Facility

    $115.27

    $9.98 lower than Chico for the office setting.

  • Rest Of Georgia

    Georgia · 42804

    Office

    $198.52

    Facility

    $107.05

    $30.91 lower than Chico for the office setting.

  • Hawaii, Guam

    Hawaii · 42804

    Office

    $235.83

    Facility

    $119.24

    $6.40 higher than Chico for the office setting.

  • Iowa

    Iowa · 42804

    Office

    $197.59

    Facility

    $103.76

    $31.84 lower than Chico for the office setting.

  • Idaho

    Idaho · 42804

    Office

    $198.88

    Facility

    $104.54

    $30.55 lower than Chico for the office setting.

  • East St. Louis

    Illinois · 42804

    Office

    $208.15

    Facility

    $113.81

    $21.28 lower than Chico for the office setting.

  • Rest Of Illinois

    Illinois · 42804

    Office

    $204.26

    Facility

    $110.64

    $25.17 lower than Chico for the office setting.

  • Suburban Chicago

    Illinois · 42804

    Office

    $224.89

    Facility

    $119.58

    $4.54 lower than Chico for the office setting.

  • Indiana

    Indiana · 42804

    Office

    $200.13

    Facility

    $105.07

    $29.30 lower than Chico for the office setting.

  • Kansas

    Kansas · 42804

    Office

    $196.39

    Facility

    $103.69

    $33.04 lower than Chico for the office setting.

  • Kentucky

    Kentucky · 42804

    Office

    $196.35

    Facility

    $105.19

    $33.08 lower than Chico for the office setting.

  • New Orleans

    Louisiana · 42804

    Office

    $206.38

    Facility

    $109.89

    $23.05 lower than Chico for the office setting.

  • Rest Of Louisiana

    Louisiana · 42804

    Office

    $195.94

    Facility

    $105.19

    $33.49 lower than Chico for the office setting.

  • Metropolitan Boston

    Massachusetts · 42804

    Office

    $248.96

    Facility

    $126.53

    $19.53 higher than Chico for the office setting.

  • Rest Of Massachusetts

    Massachusetts · 42804

    Office

    $223.76

    Facility

    $115.78

    $5.67 lower than Chico for the office setting.

  • Baltimore/Surr. Cntys

    Maryland · 42804

    Office

    $229.75

    Facility

    $119.72

    $0.32 higher than Chico for the office setting.

  • Rest Of Maryland

    Maryland · 42804

    Office

    $217.37

    Facility

    $113.60

    $12.06 lower than Chico for the office setting.

  • Rest Of Maine

    Maine · 42804

    Office

    $199.78

    Facility

    $105.44

    $29.65 lower than Chico for the office setting.

  • Southern Maine

    Maine · 42804

    Office

    $211.71

    Facility

    $110.09

    $17.72 lower than Chico for the office setting.

  • Detroit

    Michigan · 42804

    Office

    $213.70

    Facility

    $114.75

    $15.73 lower than Chico for the office setting.

  • Rest Of Michigan

    Michigan · 42804

    Office

    $201.65

    Facility

    $108.03

    $27.78 lower than Chico for the office setting.

  • Minnesota

    Minnesota · 42804

    Office

    $216.06

    Facility

    $110.54

    $13.37 lower than Chico for the office setting.

  • Metropolitan Kansas City

    Missouri · 42804

    Office

    $205.09

    Facility

    $108.80

    $24.34 lower than Chico for the office setting.

  • Metropolitan St. Louis

    Missouri · 42804

    Office

    $207.42

    Facility

    $109.80

    $22.01 lower than Chico for the office setting.

  • Rest Of Missouri

    Missouri · 42804

    Office

    $192.19

    Facility

    $103.80

    $37.24 lower than Chico for the office setting.

  • Mississippi

    Mississippi · 42804

    Office

    $190.61

    Facility

    $102.32

    $38.82 lower than Chico for the office setting.

  • Montana**

    Montana · 42804

    Office

    $215.42

    Facility

    $112.88

    $14.01 lower than Chico for the office setting.

  • North Carolina

    North Carolina · 42804

    Office

    $202.05

    Facility

    $106.38

    $27.38 lower than Chico for the office setting.

  • North Dakota**

    North Dakota · 42804

    Office

    $211.86

    Facility

    $109.32

    $17.57 lower than Chico for the office setting.

  • Nebraska

    Nebraska · 42804

    Office

    $198.81

    Facility

    $104.17

    $30.62 lower than Chico for the office setting.

  • New Hampshire

    New Hampshire · 42804

    Office

    $221.55

    Facility

    $114.80

    $7.88 lower than Chico for the office setting.

  • Northern Nj

    New Jersey · 42804

    Office

    $245.27

    Facility

    $126.32

    $15.84 higher than Chico for the office setting.

  • Rest Of New Jersey

    New Jersey · 42804

    Office

    $233.10

    Facility

    $121.12

    $3.67 higher than Chico for the office setting.

  • New Mexico

    New Mexico · 42804

    Office

    $202.76

    Facility

    $108.73

    $26.67 lower than Chico for the office setting.

  • Nevada**

    Nevada · 42804

    Office

    $214.60

    Facility

    $111.96

    $14.83 lower than Chico for the office setting.

  • Nyc Suburbs/Long Island

    New York · 42804

    Office

    $254.91

    Facility

    $132.99

    $25.48 higher than Chico for the office setting.

  • Poughkpsie/N Nyc Suburbs

    New York · 42804

    Office

    $234.49

    Facility

    $122.21

    $5.06 higher than Chico for the office setting.

  • Queens

    New York · 42804

    Office

    $251.24

    Facility

    $130.04

    $21.81 higher than Chico for the office setting.

  • Rest Of New York

    New York · 42804

    Office

    $205.28

    Facility

    $107.87

    $24.15 lower than Chico for the office setting.

  • Ohio

    Ohio · 42804

    Office

    $200.93

    Facility

    $107.31

    $28.50 lower than Chico for the office setting.

  • Oklahoma

    Oklahoma · 42804

    Office

    $196.19

    Facility

    $104.62

    $33.24 lower than Chico for the office setting.

  • Portland

    Oregon · 42804

    Office

    $233.14

    Facility

    $119.22

    $3.71 higher than Chico for the office setting.

  • Rest Of Oregon

    Oregon · 42804

    Office

    $212.98

    Facility

    $110.85

    $16.45 lower than Chico for the office setting.

  • Metropolitan Philadelphia

    Pennsylvania · 42804

    Office

    $224.21

    Facility

    $117.47

    $5.22 lower than Chico for the office setting.

  • Rest Of Pennsylvania

    Pennsylvania · 42804

    Office

    $201.38

    Facility

    $107.25

    $28.05 lower than Chico for the office setting.

  • Puerto Rico

    Puerto Rico · 42804

    Office

    $217.19

    Facility

    $113.52

    $12.24 lower than Chico for the office setting.

  • Rhode Island

    Rhode Island · 42804

    Office

    $221.11

    Facility

    $115.18

    $8.32 lower than Chico for the office setting.

  • South Carolina

    South Carolina · 42804

    Office

    $201.82

    Facility

    $107.07

    $27.61 lower than Chico for the office setting.

  • South Dakota**

    South Dakota · 42804

    Office

    $211.44

    Facility

    $108.90

    $17.99 lower than Chico for the office setting.

  • Tennessee

    Tennessee · 42804

    Office

    $197.42

    Facility

    $104.21

    $32.01 lower than Chico for the office setting.

  • Austin

    Texas · 42804

    Office

    $224.54

    Facility

    $116.05

    $4.89 lower than Chico for the office setting.

  • Beaumont

    Texas · 42804

    Office

    $199.95

    Facility

    $106.64

    $29.48 lower than Chico for the office setting.

  • Brazoria

    Texas · 42804

    Office

    $212.94

    Facility

    $111.33

    $16.49 lower than Chico for the office setting.

  • Dallas

    Texas · 42804

    Office

    $214.29

    Facility

    $112.16

    $15.14 lower than Chico for the office setting.

  • Fort Worth

    Texas · 42804

    Office

    $212.70

    Facility

    $111.59

    $16.73 lower than Chico for the office setting.

  • Galveston

    Texas · 42804

    Office

    $213.57

    Facility

    $111.74

    $15.86 lower than Chico for the office setting.

  • Houston

    Texas · 42804

    Office

    $216.86

    Facility

    $115.04

    $12.57 lower than Chico for the office setting.

  • Rest Of Texas

    Texas · 42804

    Office

    $206.32

    Facility

    $109.01

    $23.11 lower than Chico for the office setting.

  • Utah

    Utah · 42804

    Office

    $204.78

    Facility

    $108.39

    $24.65 lower than Chico for the office setting.

  • Virginia

    Virginia · 42804

    Office

    $210.82

    Facility

    $110.03

    $18.61 lower than Chico for the office setting.

  • Virgin Islands

    United States Virgin Islands · 42804

    Office

    $217.19

    Facility

    $113.52

    $12.24 lower than Chico for the office setting.

  • Vermont

    Vermont · 42804

    Office

    $210.79

    Facility

    $109.28

    $18.64 lower than Chico for the office setting.

  • Rest Of Washington

    Washington · 42804

    Office

    $223.41

    Facility

    $115.44

    $6.02 lower than Chico for the office setting.

  • Seattle (King Cnty)

    Washington · 42804

    Office

    $254.43

    Facility

    $128.61

    $25.00 higher than Chico for the office setting.

  • Wisconsin

    Wisconsin · 42804

    Office

    $204.25

    Facility

    $106.01

    $25.18 lower than Chico for the office setting.

  • West Virginia

    West Virginia · 42804

    Office

    $196.11

    Facility

    $107.00

    $33.32 lower than Chico for the office setting.

  • Wyoming**

    Wyoming · 42804

    Office

    $213.87

    Facility

    $111.33

    $15.56 lower than Chico for the office setting.

See how rates vary across the country

42804 · Office / nonfacility · Non-QP. Choose a state to explore its payment localities. A range means the amount varies within that state.

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.

$188.93

$260.34

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

View all state and territory rates as a table
State / territoryRate rangeLocalities
AK$244.661
AL$191.911
AR$188.931
AZ$209.381
CA$229.43–$291.2429
CO$225.331
CT$230.431
DC$248.171
DE$213.031
FL$211.10–$231.493
GA$198.52–$219.452
GU$235.831
HI$235.831
IA$197.591
ID$198.881
IL$204.26–$224.894
IN$200.131
KS$196.391
KY$196.351
LA$195.94–$206.382
MA$223.76–$248.962
MD$217.37–$248.173
ME$199.78–$211.712
MI$201.65–$213.702
MN$216.061
MO$192.19–$207.423
MS$190.611
MT$215.421
NC$202.051
ND$211.861
NE$198.811
NH$221.551
NJ$233.10–$245.272
NM$202.761
NV$214.601
NY$205.28–$254.915
OH$200.931
OK$196.191
OR$212.98–$233.142
PA$201.38–$224.212
PR$217.191
RI$221.111
SC$201.821
SD$211.441
TN$197.421
TX$199.95–$224.548
UT$204.781
VA$210.82–$248.172
VI$217.191
VT$210.791
WA$223.41–$254.432
WI$204.251
WV$196.111
WY$213.871

Explore 42804 on the national rate map →

Where does this rate apply?

Chico is a Medicare payment area. Our Census mapping connects it to 30 cities and communities in California, including the examples shown here.

Some communities span more than one payment area. Follow a city link to compare all of its mapped areas, or check the service-location ZIP above for an address-level starting point.

Browse all communities in California →

Why are the office and facility amounts different?

For 42804 in Chico, the physician’s office rate is $229.43 and the facility-setting rate is $117.04: a difference of $112.39.

The calculation uses a different practice-expense RVU for each setting. Both amounts here are physician fee-schedule amounts. The facility figure does not include a hospital’s separate charges, so this comparison does not tell you the total cost of receiving care in each setting.

See the inputs behind this difference →

Use this rate

What is a percentage of Medicare worth?

Turn a percentage into dollars for 42804 in Chico. This uses the base rate on this page, so the locality and release stay consistent.

Reference amount per service

$252.37

$229.43 × 110% = $252.37

A contract may specify another Medicare year or additional adjustments. This is percentage arithmetic on the displayed base rate, not a claim adjudication.

Working with a whole code list?

Compare an offer across your annual code mix, including an older Medicare schedule or flat per-code rates.

Compare your contract offer →

How this local rate is calculated

Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 42804 in Chico.

PPRRVU2026_Oct_nonQPP.csv

5,072

Code
42804
Physician work
1.26
Practice expense
5.01
Malpractice
0.18

GPCI2026.csv

9

Locality
Chico
Physician work
1.017
Practice expense
1.096
Malpractice
0.536
Office / nonfacility calculation for 42804 in Chico
ComponentRVULocality factorAdjusted
Physician work1.26× 1.0171.2814
Practice expense5.01× 1.0965.4910
Malpractice0.18× 0.5360.0965
Total RVUs6.8689
Conversion factor× 33.4009

Office / nonfacility rate, Chico$229.43

Values as parsed from CMS release RVU26D, effective 2026-10-01. The amount is rounded to the nearest cent only at the end.

Open 42804 in the RVU calculator →

Explore RVUs, geographic factors and the full formula

Office / nonfacility

Office / nonfacility calculation inputs
ComponentRVULocal GPCI
Work1.261.017
Practice expense5.011.096
Malpractice0.180.536

(1.26 × 1.017 + 5.01 × 1.096 + 0.18 × 0.536) × $33.4009 = $229.43

Facility

Facility calculation inputs
ComponentRVULocal GPCI
Work1.261.017
Practice expense1.941.096
Malpractice0.180.536

(1.26 × 1.017 + 1.94 × 1.096 + 0.18 × 0.536) × $33.4009 = $117.04

The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.

How this rate has changed

42804 · Office / nonfacility

$229.43

Effective 2026-10-01

The base rate is $8.50 higher than on 2025-10-01, moving from $220.93 to $229.43 (3.8%).

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

    $220.93changed to$229.43

    • Conversion factor 32.3465 changed to 33.4009
    • Work RVU 1.29 changed to 1.26
    • Practice expense RVU 4.96 changed to 5.01
    • Work GPCI 1.014 changed to 1.017
    • Practice expense GPCI 1.093 changed to 1.096
    • Malpractice GPCI 0.560 changed to 0.536

    Held through RVU26B, RVU26C, RVU26D.

  2. January 1, 2025

    RVU25A

    Earliest loaded release: $220.93

    Held through RVU25B, RVU25C, RVU25D.

Explore release dates and calculate this code in an earlier period →

Each row uses the accepted CMS release effective on that date and the same contractor and locality identifiers. Missing rates stay visible. Historical boundaries may differ; verify the service address for an older claim.

Inspect every release and its CMS source
Effective fromOffice / nonfacilityFacilityCMS release
2026-10-01$229.43$117.04RVU26D
2026-07-01$229.43$117.04RVU26C
2026-04-01$229.43$117.04RVU26B
2026-01-01$229.43$117.04RVU26A
2025-10-01$220.93$125.47RVU25D
2025-07-01$220.93$125.47RVU25C
2025-04-01$220.93$125.47RVU25B
2025-01-01$220.93$125.47RVU25A

42804 billing questions

How does this differ from code 42800?

Code 42804 is for tissue sampled from the nasopharynx. Code 42800 is used when the sampled site is the oropharynx.

How does this differ from code 42806?

Both codes concern nasopharyngeal biopsy. Use the code that matches the documented biopsy service and approach; do not select between them based only on the diagnosis or specimen.

Can a biopsy and lesion excision be reported as the same service?

No. Code 42804 represents obtaining a biopsy specimen; code 42808 describes excision of a pharyngeal lesion. The operative documentation should show which service was performed.

Should modifier 50 be appended for bilateral sampling?

No. The CMS bilateral adjustment does not apply to this code, and modifier 50 is inappropriate.

How does the multiple procedure reduction affect payment?

When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and the others are subject to the standard 50% reduction.

Are related postoperative visits included?

Yes. Related postoperative visits during the 10-day global period are included in the procedure.

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense, and malpractice RVUs, adjusted by each locality’s geographic indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.

Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.

RVUs for 42804PPRRVU2026_Oct_nonQPP.csv, line 5,072 (RVU26D)
Geographic factors for ChicoGPCI2026.csv, line 9 (RVU26D)
Open CMS sourceHow this rate is calculatedBuild a fee sheet