Medicare 2026 Physician Fees for Endovenous Laser Ablation and Circumcision: What Is Work, What Is Practice Expense, and What CMS Prices for the Kit

What $980.32 and $246.83 contain on CPT 36478

In the July and October 2026 files, CPT 36478 carries work RVU 5.17 in both settings, non-facility practice expense 23.09, and facility practice expense 1.13. The code is status A, global 000, malpractice RVU 1.09, non-facility total 29.35, and facility total 7.39. ^{1 2}

The arithmetic is the row times that factor, rounded half up to the cent.

• Work, 5.17 × 33.4009, is $172.68 in both settings.
• Non-facility practice expense, 23.09 × 33.4009, is $771.23.
• Facility practice expense, 1.13 × 33.4009, is $37.74.
• Malpractice, 1.09 × 33.4009, is $36.41.
• The non-facility total, 29.35 × 33.4009, is $980.32. The three rounded office components sum to that total.
• The facility total, 7.39 × 33.4009, is $246.83. The three rounded facility components sum to that total.

Of the 29.35 non-facility total RVUs, work is 17.6 percent and non-facility practice expense is 78.7 percent. Of the 7.39 facility total RVUs, the same work RVU is 70.0 percent and facility practice expense is 15.3 percent. At geographic index 1.0 those RVU shares are the dollar shares. A locality index moves the dollar share, because each component is multiplied by its own geographic practice cost index before the conversion factor. ¹

Work stays $172.68 in both settings. The $733.49 gap between $980.32 and $246.83 is practice expense: $771.23 in the office and $37.74 on the facility physician fee.

CMS describes the two rates in the 31 October 2025 fact sheet. "For most services furnished in a physician's office, Medicare makes payment to physicians and other professionals at a single rate based on the full range of resources involved in furnishing the service. In contrast, PFS rates paid to physicians and other billing practitioners in facility settings, such as a hospital outpatient department (HOPD) or an ASC, reflect only the portion of the resources typically incurred by the practitioner while furnishing the service." ³

The final rule states the same split as a practice-expense method. Where a procedure can be furnished in a physician's office and in a facility, and Medicare makes a separate payment to the facility, CMS establishes two practice-expense RVUs, facility and non-facility. The facility physician RVU keeps the practitioner's portion of the resources. ⁴

The qualifying-APM conversion factor in the October file is 33.5675. At that factor the 36478 totals are $985.21 non-facility and $248.06 facility, and the work component is $173.54. The qualifying office amount sits $4.89 above the non-qualifying office amount. The setting gap is $733.49. ¹

These amounts use geographic index 1.0. A Medicare Administrative Contractor then applies locality indices, and deductible and coinsurance come after that. The 2024 allowed amount and Medicare payment below are a different year. ¹

July and October are the payment files

July 2026 and October 2026 match on CPT 36478: work 5.17, non-facility practice expense 23.09, facility practice expense 1.13. They also match on malpractice, both totals, and the NA indicator for every unmodified code in the tables below. The July non-qualifying rows store conversion factor 33.4009. The October file stores 33.4009 for non-qualifying clinicians and 33.5675 for qualifying APM participants. The October header reads released 26 August 2026. ^{1 2}

RVU26D.pdf sets the arithmetic. The 2026 non-facility pricing amount is [(work RVU × work GPCI) + (non-facility PE RVU × PE GPCI) + (malpractice RVU × malpractice GPCI)] × conversion factor. The facility amount uses the facility PE RVU in place of the non-facility PE RVU. Generally, facility practice-expense RVUs apply in inpatient and outpatient hospitals, emergency rooms, skilled nursing facilities, and ambulatory surgical centers, and non-facility practice-expense RVUs apply in the other settings. ¹

The final rule's impact section estimates the qualifying factor at $33.5675 and the non-qualifying factor at $33.4009. ⁴ The fact sheet rounds those factors to $33.57 and $33.40, from $32.35 in CY 2025. ³ The dollars in this article use the factors stored on the file rows, 33.4009 and 33.5675. Multiplying the 36478 office total by the fact sheet's displayed $33.40 produces $980.29, three cents under the $980.32 from the factor stored on the row.

The last three amount columns on these relative-value rows are 0.00. The file documentation places those columns under the imaging payment cap that compares a technical component with the hospital outpatient amount. The fee-schedule amount is the formula above. ¹

The July and October relative value files are the payment source. Addendum B, the 3 November 2025 workbook in the addenda zip updated 26 February 2026, prints non-facility practice expense 0.01 to 0.04 higher on seven ablation codes, 36465, 36466, 36473, 36475, 36476, 36478, and 36482, including 23.10 and total 29.36 on 36478, which prices to $980.65, $0.33 above the quarterly $980.32, and the files read here contain no correction notice for that difference. ^{5 2}

Ten endovenous codes, with work and practice expense separated

On every code in this set, work is one number and practice expense is two. The non-facility fee-schedule amount is large where the non-facility practice-expense RVU is large. Global surgery indicators sort the ten codes before anyone prices a kit. RVU26D.pdf defines 000 as an endoscopic or minor procedure whose related preoperative and postoperative values on the day of the procedure are included in the fee-schedule amount. It defines ZZZ as a code related to another service and always included in the global period of that other service. The four ZZZ codes, 36474, 36476, 36479, and 36483, are add-on amounts. ¹

Unmodified rows, July 2026 and October 2026, which match. Amounts are total RVUs times 33.4009, geographic index 1.0, rounded half up to the cent. Full CPT descriptors are withheld. ^{1 2}

CPT 36475 and CPT 36478 have the same work RVU, 5.17, and the same work dollars, $172.68. The office amounts differ by $75.82, $1,056.14 against $980.32, because the non-facility practice-expense RVUs are 25.30 and 23.09. CPT 36482 runs the other way: work RVU 3.41 and an office amount of $1,657.35. A higher office allowance in this table is a larger practice-expense RVU.

Every unmodified row read for these codes, and for the three circumcision codes below, has status A, an active code paid separately under the physician fee schedule if covered. The FAQ quotes the coverage sentence in that definition. ¹

The laser-treatment kit is a $438.60 supply input

The direct-supply file prices one unit of SA074, "kit, endovascular laser treatment," at $438.60 on CPT 36478 in the non-facility setting and at quantity 0 in the facility setting. All 38 supply rows on 36478 have facility quantity 0. The non-facility supply total on the code is 600.491. The kit is the largest of those rows. The next row is compression stockings at $41.20. ⁶

CMS's supply file labels some items with product names. This article uses the supply code and a modality label in their place: cyanoacrylate adhesive (SD323), polidocanol microfoam (SD324), mechanochemical ablation kit (SA122), and RF catheter (SD155). The file also labels SH108 with a product name, and the worksheet calls that row the sclerosing-agent input. SA074 keeps the file's generic words, kit, endovascular laser treatment.

The office supply input runs from the $438.60 laser kit to the $1,495 cyanoacrylate adhesive. The microfoam bar is $1,054.35, the extended amount from a $3,195 unit at quantity 0.33. Facility quantity on every row is 0.

CMS-1832-F supply public-use file, inner files dated 20 October 2025. Extended input is unit price times the file quantity. The modality labels replace product names printed in the file. ⁶

The $438.60 kit is one direct input inside the 23.09 non-facility practice-expense RVU. The $771.23 figure is the practice-expense component, and the $980.32 figure is the physician fee-schedule amount. A kit quote sits beside the $438.60 input. In CMS's example, a service with a direct-cost sum of $400 would have twice the direct portion of the practice-expense RVUs of a service with a direct-cost sum of $200. ⁴ Direct costs are then scaled, and indirect practice expense is allocated, before an RVU becomes a fee-schedule dollar. This comparison leaves that scaling as CMS built it and assigns no share of the $771.23 to the kit.

On 36478, equipment EQ160, "laser, endovascular ablation (ELVS)," has purchase price 64,938.824, useful life 5, utilization 0.5, 63 non-facility minutes, and 0 facility minutes. The ultrasound room, EL015, has purchase price 410,303.322 and the same 63 and 0 minutes. The summary equipment cost for the code is 113.9738787 non-facility and 0 facility. ⁶ About $113.97 is the per-case equipment figure. The purchase price is the capital input CMS spreads over useful life and utilization.

VEMERIX, the brand of Weihai Medison, manufactures a Class II single-use 1470 nm laser fiber for endovenous laser ablation of varicose veins, NMPA Lu Mech Reg. 20192010517, and pairs that fiber with a partner-supplied diode source. A distributor quoting that fiber to a US office customer sets the quote beside the worksheet row for CPT 36478 in the office: the SA074 input in one column, the non-facility practice-expense component in the next, and the work component left in the physician column.

Facility quantity 0 records that the kit is absent from the facility direct cost CMS used for the physician fee. The physician fee in that setting is the $246.83 column. The purchasing party for a hospital fiber stays outside this file. The hospital outpatient or ambulatory surgery center payment is a different system, and these files leave it unpriced.

The kit row is on 36478. Subsequent-vein code 36479 has no SA074 row. Its highest-priced supply is SD136, "vascular sheath," at $24.444, non-facility quantity 1 and facility quantity 0. The non-facility supply total on 36479 is 90.584. ⁶ A second vein billed as 36479 carries that sheath in this file. The laser-treatment kit stays on 36478.

Adhesive, microfoam, and the radiofrequency catheter

The office allowance and the work RVU run in opposite directions once the supply file is open. CPT 36482's non-qualifying office amount is $1,657.35 and its work component is $113.90, from work RVU 3.41. CPT 36478's office amount is $980.32 and its work component is $172.68, from work RVU 5.17. Non-facility practice expense is $1,518.40 on 36482 and $771.23 on 36478. The office gap of $677.03 is practice expense. Laser has the higher professional-work payment of the two codes. The adhesive code has the higher office allowance because CMS priced supply SD323 at $1,495 with non-facility quantity 1. ^{1 6}

Microfoam is the same pattern in a stronger form. CPT 36465 has work RVU 2.29, work dollars $76.49, non-facility practice expense $1,194.08, and a non-facility fee-schedule amount of $1,286.60. Supply SD324 is priced at $3,195 with non-facility quantity 0.33, so the extended input is $1,054.35. The $3,195 figure is the unit price. The per-service input is 0.33 of that unit. CPT 36466, global 000 in this file, carries another SD324 row at the same $3,195 and the same quantity 0.33, extended $1,054.35, inside a non-facility supply total of 1,283.271. ^{1 6} Each code's input is 0.33 of a unit. The two inputs stay inside their own codes.

The radiofrequency primary code is the supply side of that same-work pair. CMS prices SD155 at $487.92 with non-facility quantity 1, $49.32 above SA074, and the non-facility practice expense on 36475 is $845.04. ^{1 6} The mechanochemical kit, SA122, is $883.33 at non-facility quantity 1 on CPT 36473, facility quantity 0, inside an office amount of $1,174.04 whose work component is $113.90.

The labels identify the supply code CMS priced. They are a valuation comparison. Modality selection is covered in Thermal and non-thermal varicose vein ablation, and the service-mix shift in Endovenous laser ablation and the varicose vein market. A 2023 office-rate article, 1470 nm endovenous laser system price and total cost, used that year's national office rates. The figures here are the CY 2026 components.

The efficiency adjustment inside the published work RVU

The work RVU published for CPT 36478 is 5.17, and that published value is already the adjusted value. ^{1 7}

For CY 2026 CMS finalized an efficiency adjustment of 2.5 percent to work RVUs and to the intraservice portion of physician time for non-time-based services, to be applied every 3 years. Bureau of Labor Statistics data "yielded an efficiency adjustment of 3.6 percent," and CMS chose 2.5 percent because the approach "is designed to be conservative in nature, as we are concerned about making too many changes at once." The exemptions are "time-based codes, services on the CMS telehealth list, and new codes for CY 2026," plus maternity codes with global period MMM. ^{4 3} None of these thirteen codes is MMM. In the 17 November 2025 workbook, all thirteen sit on SUBJECT TO EFF MOD (7,689 data rows) and the exclusion sheet (1,059 data rows) lists none of them. Adjusted work equals the published work RVU, and it equals pre-adjustment work times 0.975, rounded half up to two decimals. ⁷

For 36478 the sheet moves work from 5.30 to 5.17 and total time from 94 to 92.88. The 5.30 figure is that workbook column. A CY 2025 relative value file was outside this reading. Total time falls by 1.12 minutes because the percentage applies to the intraservice portion. Priced at 33.4009, the 0.13 work-RVU difference is $4.34. Two and a half percent of the $980.32 office amount would be $24.51, a figure that applies the percentage to the whole allowance. VEMERIX reading. The workbook's cut on this code is the $4.34 work difference. Year-to-year movement in the allowance also includes practice-expense RVUs, the conversion factor, and geography. ^{1 4 7}

Difference equals the workbook's pre-adjustment work RVU minus the published work RVU, times 33.4009, rounded half up to the cent. It is the work-component adjustment in 2026 dollars. ^{7 1}

Commenters objected to applying what they called a productivity adjustment to reduce PFS payments "when there is no corresponding market basket or inflationary adjustment to increase PFS payments annually." ⁴ CMS finalized 2.5 percent after that comment. On these codes the workbook records the work column above.

A second CY 2026 method change stays off that column. CMS reduced "the portion of the facility PE RVUs allocated based on work RVUs to half the amount allocated to non-facility PE RVUs beginning in CY 2026." ⁴ That sentence is indirect practice expense. The zero on SA074 is a direct-input quantity. A third decision, the fact sheet's use of hospital-outpatient data for "radiation treatment services, and for some remote monitoring services," covers a different set of codes from the ablation and circumcision rows here. ³

Which 2026 column matches the common Medicare setting

The CY 2026 non-facility fee-schedule amount for 36478 is $980.32, and the facility physician amount is $246.83. Which of those columns was the common Original Medicare physician claim in 2024 is a separate file, and a separate year.

The Medicare Physician & Other Practitioners data dictionary codes place of service as facility (F) or non-facility (O). Non-facility is generally an office setting, and other entities are included in non-facility. National geography aggregates across states. ⁸ In the 2024 national file, CPT 36478 has 28,944 non-facility services and 3,163 facility services. The non-facility row has 15,567 beneficiaries and 1,330 providers. The facility row has 1,775 beneficiaries and 396 providers. ⁹

The same 36478 office row reports an average allowed amount of 929.13 and an average Medicare payment of 732.74. The payment figure is lower than the allowed amount, and both are 2024 statistics. ⁹

A published VEMERIX article already reported the 2024 national laser totals for 36478 and 36479 combined: 32,505 office services and 3,379 facility services, and said that mix is a description of where Medicare was billed. ¹⁰ The 28,944 and 3,163 figures here are the first-vein code only, the same national cut.

The facility count is the practitioner's claim. Hospital outpatient and ambulatory surgery center payments were left unretrieved, so $246.83 remains the physician column, with the kit's facility quantity at 0.

Noridian's Jurisdiction F Part B note, last updated 18 March 2026, already tells billers that more than one place of service is in view for the radiofrequency codes. The appropriate places of service it names for CPT 36475 and 36476 are 11, 19, 22, 24, and 50, and it lists other places as inappropriate. The page states neither 2026 relative value units nor a 36478 list. ¹¹ What this article adds is the 2026 dollar split, the supply inputs by code, and the 54161 display.

One utilization cell stays unpublished. CPT 36474 has a national non-facility row of 100 services and no national facility row. The suppression rule for this dataset was outside the files retrieved, so the missing facility row supplies no verified count of zero. ⁹

CPT 54161 prints NA in the non-facility cells

Addendum B prints NA in the non-facility practice-expense cell and the non-facility total cell for CPT 54161. The non-qualifying facility fee-schedule amount is $181.03. Work on that facility amount is $108.22, facility practice expense is $58.79, and malpractice is $14.03. ^{5 1} The three rounded components sum to $181.04, one cent above the rounded total. The fee-schedule amount is the total, 5.42 × 33.4009.

The quarterly files fill the blank by copying. The non-facility NA indicator is NA, the non-facility practice-expense cell repeats 1.76, and both totals are 5.42. ^{1 2} Multiplying that copied 5.42 by 33.4009 returns $181.03, the facility physician amount. Addendum B is the file that prints NA in the non-facility cells. ⁵ VEMERIX reading. The figure to withhold from a circumcision-device budget is that copied total.

RVU26D.pdf defines the indicator. "An 'NA' in this field indicates that this procedure is rarely or never performed in the non-facility setting." CMS uses that indicator for services for which it developed no separate non-facility practice-expense RVU. ¹ The direct-practice-expense summary sets "Need NF PE" to N on 54161 and leaves non-facility supply and equipment costs blank. ⁶

That indicator is CMS's pricing flag. The 2024 national physician-and-supplier file still has a non-facility row for 54161: 248 services, against 5,948 facility services. ⁹ The flag records that CMS published no separate non-facility price for 2026. The 248 services record that a non-facility claim was submitted in 2024. The two records sit side by side. CMS's phrase "rarely or never" is the wording of the pricing flag.

On 54150 and 54160, supply SA086, "tray, circumcision," is $23.54, non-facility quantity 1 and facility quantity 0. Non-facility supply totals are 32.51 and 53.29. CPT 54161's three facility-only rows are a visit pack at $4.01, sterile gloves at $0.91, and sterile gauze at $0.19, and the facility supply cost is 5.11. Across the three codes the priced descriptions include the tray and omit a stapler. ⁶ Only 54161 is flagged Need NF PE = N. Global 000 on 54150 includes the related values on the day of the procedure. Global 010 on 54160 and 54161 includes those day-of values and postoperative values during a 10-day period. At 33.4009, 54150 is $151.97 non-facility and $84.17 facility, and 54160 is $228.46 non-facility and $132.27 facility. ¹

CPT 54160 is priced for 2026, with non-facility total RVU 6.84 and a non-facility amount of $228.46. The 2024 geography-and-service API returned no rows for it. An empty public utilization result is an unpublished cell. The suppression threshold stayed outside the files retrieved, so the empty result supplies no verified count of zero services. ^{9 1}

Coverage policy for newborn or adult circumcision stayed outside this research. Service counts are claim volume, and the FAQ holds the status A coverage sentence. VEMERIX's surgical line includes disposable circumcision devices. The clinical literature on those devices is in From scalpel-and-suture to a single click. This article stays with the practice-expense file.

Worksheet for a quote

For an office 36478, the CMS supply input is $438.60 and the non-facility practice-expense component is $771.23. Work is $172.68. In the facility direct-supply file the kit quantity is 0. For 54161, Addendum B prints NA in the non-facility cells.

The worksheet uses the July and October relative value units, which match, the non-qualifying factor 33.4009, and geographic index 1.0. Rounded components differ by one cent from the rounded total on non-facility 36475, 36476, and 54150 and on facility 36475, 36482, 36483, and 54161, and the fee-schedule amount is the total RVU times 33.4009.

Malpractice sits inside the fee-schedule amount and is omitted from the columns below. On 36478 it is $36.41 at this factor. ZZZ codes are add-on amounts, included in the global period of the primary service. ¹

Extended microfoam input is price times quantity. Fee-schedule amounts are total RVUs times 33.4009. Work dollars on 54161 are the published work RVU. The office total on that row is the NA cell. ^{1 6}

Read the 36478 office row as the companions to a fiber quote, and the facility physician amount, with SA074 quantity 0, when the physician bills in a hospital or ASC. A second vein coded 36479 adds the sheath row, and the laser kit stays on 36478. On 54161, read the office amount as NA. The $181.03 on that row is the facility physician amount, beside 248 non-facility services in the 2024 file.

A distributor can send the 36478 office row with a US office quote: work $172.68, non-facility practice expense $771.23, SA074 input $438.60. Commercial payment and Medicare Advantage payment sit outside these files. Noridian's place-of-service list was retrieved for 36475 and 36476 only.

What stays outside this arithmetic

Locality indices, hospital outpatient and ambulatory surgery center payments, a CY 2025 relative value file, and the 2024 suppression threshold sit outside the arithmetic above. The durable-medical-equipment fee file was left unscanned for a separate laser-fiber code, so payment outside the physician fee schedule remains an open question, distinct from verified absence. The direct-practice-expense files are the final-rule files dated 20 October 2025. The pre-adjustment work figures are the 17 November 2025 workbook. A coding page from the Society for Vascular Surgery, the Society of Interventional Radiology, or the American Venous Forum was outside the sources read.

Frequently asked questions

Does status A mean Medicare covers vein ablation or circumcision?

RVU26D.pdf answers that directly. "The presence of an 'A' indicator does not mean that Medicare has made a national coverage determination regarding the service; A/B MACs (B) remain responsible for coverage decisions in the absence of a national Medicare policy." ¹ On these thirteen codes, A means an active code, paid separately under the physician fee schedule if covered. Circumcision coverage policy stayed outside this research.