How much does Medicare pay for CPT 21085?

Medicare allowed an average of $649.17 per service and paid $508.69 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1566.99, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 21085?

Impression and custom preparation of oral surgical splint. It was billed 1,295 times to 1,084 Medicare beneficiaries by 38 providers in 2024.

Does 21085 pay differently in an office than a hospital?

Yes. The allowed amount averaged $653.87 in an office setting and $469.35 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 21085 most?

Oral Surgery (Dentist only), with 814 services from 24 clinicians. Next are Dentist, Otolaryngology, Maxillofacial Surgery.

CPT 21085

Impression and custom preparation of oral surgical splint

$649.17Medicare-allowed amount per service, averaged across 1,295 services

Providers submitted

$1566.99

Asking price, not received

Medicare allowed

$649.17

The fee schedule figure

Medicare paid

$508.69

Balance is patient coinsurance

Providers submitted an average of $1566.99 for this code and Medicare allowed $649.17 — 2.4× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $508.69 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $653.87
Hospital / facility: $469.35

The office rate is higher because the practice supplies the room, staff and equipment out of that payment. In a hospital the facility bills those separately, so the clinician's share is smaller — the total cost to Medicare is usually higher, not lower. 1,262 services were billed in an office setting and 33 in a facility.

Services: 1,295
Beneficiaries: 1,084
Providers billing it: 38
Total allowed: $840,675

What Medicare pays for CPT 21085

Across 1,295 services billed by 38 providers to 1,084 beneficiaries, Medicare allowed an average of $649.17 per service. That is 1.2 services per beneficiary, so this is a code patients typically receive more than once. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 21085

Specialty	Services	Beneficiaries	Avg allowed	Providers
Oral Surgery (Dentist only)	814	687	$652.51	24
Dentist	215	173	$686.70	4
Otolaryngology	125	112	$671.06	4
Maxillofacial Surgery	91	75	$608.42	4
Pain Management	31	18	$421.06	1
Undefined Physician type	19	19	$504.40	1

21085 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
California	267	$684.32	$494.72	9
Arizona	229	$585.33	$470.22	6
New Jersey	213	$697.89	$527.11	3
Texas	170	$618.79	$507.51	4
Washington	116	$751.95	$529.59	2
Michigan	81	$665.36	$518.99	2
Florida	77	$632.93	$487.36	4
Ohio	39	$626.97	$526.75	2
Maryland	28	$345.71	$265.53	1
New Mexico	23	$622.01	$508.15	1
New York	15	$781.33	$528.11	1
South Carolina	14	$421.78	$275.66	1
Virginia	12	$601.98	$488.50	1
North Carolina	11	$630.09	$463.79	1

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.