How much does Medicare pay for CPT 68801?

Medicare allowed an average of $94.82 per service and paid $71.47 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $290.72, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 68801?

Dilation of tear drainage opening. It was billed 8,462 times to 5,336 Medicare beneficiaries by 179 providers in 2024.

Does 68801 pay differently in an office than a hospital?

Yes. The allowed amount averaged $95.10 in an office setting and $57.88 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 68801 most?

Ophthalmology, with 6,176 services from 138 clinicians. Next are Optometry, Plastic and Reconstructive Surgery, Nurse Practitioner.

CPT 68801

Dilation of tear drainage opening

$94.82Medicare-allowed amount per service, averaged across 8,462 services

Providers submitted

$290.72

Asking price, not received

Medicare allowed

$94.82

The fee schedule figure

Medicare paid

$71.47

Balance is patient coinsurance

Providers submitted an average of $290.72 for this code and Medicare allowed $94.82 — 3.1× 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 $71.47 (75%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $95.10
Hospital / facility: $57.88

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. 8,398 services were billed in an office setting and 64 in a facility.

Services: 8,462
Beneficiaries: 5,336
Providers billing it: 179
Total allowed: $802,367

What Medicare pays for CPT 68801

Across 8,462 services billed by 179 providers to 5,336 beneficiaries, Medicare allowed an average of $94.82 per service. That is 1.6 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 68801

Specialty	Services	Beneficiaries	Avg allowed	Providers
Ophthalmology	6,176	4,209	$101.52	138
Optometry	2,239	1,088	$76.26	39
Plastic and Reconstructive Surgery	25	22	$118.82	1
Nurse Practitioner	22	17	$76.09	1

68801 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	1,843	$89.02	$60.72	28
New York	1,217	$86.40	$54.84	23
Florida	1,067	$95.59	$71.45	16
Arizona	618	$78.83	$62.72	5
Pennsylvania	463	$110.93	$81.98	12
Texas	439	$119.06	$97.85	5
Louisiana	262	$105.89	$87.88	5
Illinois	256	$87.65	$60.41	7
Kansas	215	$59.41	$50.52	3
South Carolina	204	$71.09	$50.26	6
Michigan	177	$123.94	$94.77	6
New Jersey	158	$131.66	$88.18	5
Alabama	155	$62.00	$46.66	4
North Carolina	126	$116.03	$85.35	4
Wisconsin	125	$113.68	$81.96	4
Washington	102	$115.40	$84.83	2
Colorado	98	$117.50	$78.58	3
Missouri	89	$109.03	$82.17	2
Mississippi	73	$104.98	$88.21	3
Tennessee	72	$108.73	$78.69	3
Maine	65	$123.75	$83.53	2
Virginia	64	$99.64	$68.28	3
Maryland	53	$114.81	$66.57	2
Minnesota	46	$91.05	$67.70	3
Idaho	40	$114.68	$88.62	2
Georgia	40	$86.69	$71.37	2
Utah	37	$95.07	$73.60	2
Montana	37	$103.83	$70.26	3
Iowa	37	$96.31	$76.12	1
New Hampshire	34	$47.61	$33.26	1
South Dakota	33	$119.22	$89.82	1
Hawaii	27	$149.69	$102.24	1
Ohio	25	$115.96	$86.20	1
Puerto Rico	24	$93.65	$69.62	1
Arkansas	24	$109.12	$96.65	1
Oregon	22	$122.96	$86.40	1
Nevada	21	$46.56	$35.33	1
Massachusetts	19	$122.95	$71.10	1
Nebraska	15	$87.61	$57.43	1
Connecticut	15	$104.77	$72.74	1
Vermont	14	$51.80	$37.71	1
Oklahoma	11	$94.44	$73.00	1

Related codes

68841Insertion of drug delivery implant into tear duct of eye$16.63
68840Probing of nasal tear duct$166.24
68810Insertion of probe into nasal tear duct$210.56
68815Probing of nasal tear duct$398.65

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.