CPT 21243 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address high-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Musculoskeletal System |
| Common Place of Service | • 22 - On Campus Outpatient Hospital • 21 - Inpatient Hospital |
| Common Modifiers | • None • 50 - Bilateral Procedure • RT - Right side of body |
| Complexity Level | High |
| Medicare Fee Schedule | View Medicare rates for 21243 |
National average reimbursement for CPT 21243 by major payers:
$2,287.38
$2,220.27
$2,377.45
$2,809.65
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
Select a payer to view fee schedule data Choose a payer from the options above to see rates for CPT 21243 | ||||||
United | 21243 | $953.00 | 1871718270 - PRINCE GEORGES MULTI SPECIALTY SURGERY CENTER | 521842302 - (MD) PRINCE GEORGES MULTI SPECIALTY SURGERY CENTER | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $5354.00 | 1922510643 - OPTIMUM SPINE CENTER, LLC, PEACHTREE SPINE & PAIN PHYSICIANS | 320543789 | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $926.00 | 1396738936 - WARREN GASTRO ENDOSCOPY CTR INC | 341850936 - (OH) WARREN GASTRO ENDOSCOPY CTR INC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $1005.00 | 1376513440 - FLORIDA EYE CLINIC AMBULATORY SURGERY CENTER, INC. | 592303141 | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $5354.00 | 1275545279 - SURGERY CENTER OF COLUMBIA LP | 205227138 - (MO) SURGERY CENTER OF COLUMBIA LP | MO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $1732.00 | 1639566318 - TRIAD SURGERY CENTER, LLC | 473510624 | OK | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $1473.00 | 1538635859 - SEARCY AMBULATORY SURGERY CENTER LLC | 830756271 - (AR) SEARCY AMBULATORY SURGERY CENTER LLC | AR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $2689.00 | 1386858595 - ALDERWOOD SURGERY CENTER LLC | 204979154 - (WA) ALDERWOOD SURGICAL CENTER | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $1750.00 | 1144380593 - SURGERY CENTER OF ALLENTOWN LLC, SURGERY CENTER OF ALLENTOWN | 204532105 - (PA) SURGERY CENTER OF ALLENTOWN | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $741.00 | 1992423719 - ENDOSCOPY ASC OF MIDDLE GEORGIA LLC | 883065469 | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $1743.00 | 1831413772 - OXFORD UROCARE PLLC | 272032475 - (MS) OXFORD UROCARE PLLC | MS | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $1919.00 | 1285678979 - BAY SURGERY CENTERS LLC, CLEARWAY SURGERY CENTER OF ANNAPOLIS | 204934078 - (MD) BAY SURGERY CENTERS LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $5354.00 | 1861740508 - ADVANCED SURGERY CENTER OF SARASOTA, LLC | 454909647 - (FL) ADVANCED SURGERY CENTER OF SARASOTA LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $3750.00 | 1508810656 - RETINAL AMBULATORY SURGERY CENTER OF NEW YORK, INC. | 134189700 - (NY) RETINAL AMBULATORY SURGERY CENTER OF NY, INC. | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21243 | $2889.00 | 1467442657 - HOLY REDEEMER AMBULATORY SURGERY CENTER, LLC | 233020527 - (PA) HOLY REDEEMER AMBULATORY SURGERY CENTER LLC | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 21243 vs. Other Surgical Procedures on the Musculoskeletal System Codes
The CPT 21243 code is part of the Surgery services used for Surgical Procedures on the Musculoskeletal System. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 21243 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 21240-CPT | High | Arthroplasty Temporomandib Unil |
| 21242-CPT | High | Arthroplasty Tmj Alloplastic Agent |
| 21243-CPT | High | Arthroplasty Tmj W/Pros Jnt Replace |
| 21244-CPT | High | Reconstruction Of Mandible, Extraoral, With Transosteal Bone Plate -Commercial Rn Review>=1/1/1996: Medicaid Rn Review=1/1/1996-9/30/2020 |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 21243. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 21243 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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