CPT 21261 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 | • 21 - Inpatient Hospital |
| Common Modifiers | • None • 80 - Assistant surgeon |
| Complexity Level | High |
| Medicare Fee Schedule | View Medicare rates for 21261 |
National average reimbursement for CPT 21261 by major payers:
$2,890.53
$3,157.17
$3,204.73
$3,938.76
| 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 21261 | ||||||
United | 21261 | $4530.00 | 1316072234 - ARIA HEALTH SYSTEM, ARIA HEALTH FRANKFORD CAMPUS SPU | 230596940 - (PA) JEFFERSON HEALTH-NORTHEAST | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $2958.00 | 1063459451 - CARROLL COUNTY AMBULATORY SURGICAL CENTER | 522165022 - (MD) CARROLL COUNTY AMBULATORY SURGICAL CENTER | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $2800.00 | 1053634030 - DALLAS NEPHROLOGY ASSOCIATES, DALLAS NEPHROLOGY ASSOCIATES VASCULAR CENTER DALLAS | 751366650 - (TX) DALLAS NEPHROLOGY ASSOCIATES, P.A. | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $2043.00 | 1154318376 - LAHAYE CENTER FOR ADVANCED EYE CARE OF LAFAYETTE, INC. | 721227426 | LA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $3650.00 | 1003965328 - PACIFIC HEIGHTS SURGERY CENTER OF SAN FRANCISCO LP | 522380476 - (CA) PACIFIC HEIGHTS SURGERY CENTER | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $4248.00 | 1083653554 - UROLOGY SURGICAL PARTNERS, LLC | 582622573 - (GA) UROLOGY SURGICAL PARTNERS, LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $2574.00 | 1053362343 - SODERSTROM DERMATOLOGY CENTER S C, PEORIA AMBULATORY SURGERY CENTER | 371001642 - (IL) SODERSTROM DERMATOLOGY CENTER, S.C. | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $3000.00 | 1225023021 - ARC OF GEORGIA, LLC, PREMIER SURGERY CENTER | 621746313 - (GA) ARC OF GEORGIA LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $2163.00 | 1477502979 - INLAND EAR NOSE AND THROAT A MEDICAL GROUP INC, FOOTHILL AMBULATORY SURGERY CENTER | 953300822 - (CA) M.M. KANOK, M.D., A MEDICAL CORPORA | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $1500.00 | 1033214903 - SOUTH HILLS DIAGNOSTIC & TREATMENT CENTER LP, SOUTH HILLS ENDOSCOPY CENTER | 861117604 - (PA) SOUTH HILLS DIAGNOSTIC TREATMENT CENTER LP | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $2781.00 | 1336437482 - HEALTHONE RIDGE VIEW ENDOSCOPY CENTER, LLC, RIDGE VIEW ENDOSCOPY CENTER | 800688043 | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $5433.00 | 1235395385 - TENN SM LLC | 680569923 - (TN) TENN SM LLC | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $5433.00 | 1942472931 - SURGCENTER OF GLEN BURNIE, SURGCENTER OF GLEN BURNIE, LLC | 261572774 - (MD) SURGCENTER OF GLEN BURNIE, LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $6516.00 | 1548844400 - SAINT LUKES SOUTH PAIN MANAGEMENT CENTER LLC | 863451115 - (KS) SAINT LUKES SOUTH PAIN MANAGEMENT CENTER LLC | KS | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 21261 | $1362.00 | 1295002806 - HERITAGE ONE DAY SURGERY LLC | 453788494 - (NY) HERITAGE ONE DAY SURGERY LLC | NY | 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 21261 vs. Other Surgical Procedures on the Musculoskeletal System Codes
The CPT 21261 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 21261 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 |
|---|---|---|
| 21255-CPT | High | Recon Zygomatic Arch/Glenoid Fossa W/Aut |
| 21256-CPT | High | Reconstruction Of Orbit With Osteotomies (Extracranial) And With Bone Grafts (Includes Obtaining Autografts) (Eg, Micro-Ophthalmia) |
| 21260-CPT | High | Periorbital Osteotomy W/Graft Extracrani |
| 21261-CPT | High | Rep Orbit Hypertelorism Combin Appr |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 21261. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 21261 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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