Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis
What Medicare pays for 21243, what providers bill, and how the price varies across 3 states, drawn from CMS 2023 claims data.
21243 · the short answer
For repair of hinged joint of upper and lower jaw bones with prosthesis, Medicare pays about $1,362.96 while providers bill $14,140.73 on average, a 10.4× markup, one of the steepest markups in the catalog. State-level Medicare rates range 30% from lowest to highest.
- Medicare pays
- $1,362.96
- Providers bill
- $14,140.73
- Markup
- 10.4×
- Markup percentile
- 91th
Medicare amounts are CMS-published; markup = average submitted charge ÷ average Medicare payment.
Price Range Across States
What You Might Pay
Estimated using RAND 2024 commercial-to-Medicare ratios. Actual prices vary by insurer, plan, and facility.
How we estimate these prices
These estimates are based on the RAND Hospital Price Transparency Study (4th Edition, 2024), which found that commercial insurance prices average 224% of Medicare rates nationally. We apply category-specific ratios: Musculoskeletal Surgery procedures average 2.24x Medicare rates. Cash/self-pay estimates blend typical cash discounts (55% of billed charges) with Medicare-based estimates (150% of allowed amounts). These are statistical estimates, not quotes. Contact your insurer or provider for actual costs.
Where this markup sits nationally
Markup (billed ÷ Medicare) across 8,901 procedures with a meaningful Medicare rate
10 Among the most affordable more affordable than 91% of 8,901 procedures
Each bar is a band; taller bars hold more procedures. The dashed line + filled bar mark this entry. Hover or tap any bar for its full count, share, and where it sits relative to this entry.
Source CMS Medicare Physician & Other Practitioners · 2023
Prices by State
| State | Medicare Payment | Billed Charge |
|---|---|---|
| New York | $1,496.04 | $38,417.88 |
| Pennsylvania | $1,281.02 | $8,440.69 |
| Texas | $1,148.31 | $7,619.62 |
What the Data Says About Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis
Across 3 states with reporting providers, CPT code 21243 (Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis) shows a national average Medicare payment of $1,362.96 against an average billed charge of $14,140.73. That gap, a 10.4x markup, or 938% above the Medicare allowed amount, sits among the widest billed-to-paid spreads we track, the kind of chargemaster pricing almost no payer, insured or cash, actually honors in full.
Musculoskeletal Surgery procedures like this one saw 139 services billed to Medicare in 2023 by 71 distinct providers, serving 122 unique beneficiaries. State-level variation is significant: Texas reports the lowest average payment at $1,148.31, while New York reports the highest at $1,496.04. The 30% spread here is a moderate, fairly ordinary GPCI effect, local cost-of-practice adjustments nudging the allowed amount up or down without reshaping it.
Applying RAND 2024 commercial-to-Medicare ratios specific to the Musculoskeletal Surgery category (2.24x), the estimated commercial insurance price lands near $3,840.22, with self-pay cash discounts commonly bringing the figure closer to $5,174.49. Within Musculoskeletal Surgery, Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis ranks #32 of 1411 tracked procedures by national average Medicare payment.
What to do with this
If you may have repair of hinged joint of upper and lower jaw bones with prosthesis done, these steps turn the numbers above into a real-world cost estimate.
- Request a Good Faith Estimate from your provider at least 3 business days before a scheduled procedure, under the No Surprises Act it is an enforceable written price.
- Compare repair of hinged joint of upper and lower jaw bones with prosthesis costs in your state, Medicare rates vary by locality. Browse states
- Check a hospital’s published cash price, which is often far below the billed charge. Price transparency
- Understand why billed charges run several times the Medicare rate before you negotiate. Read the guide
Figures here are averages and estimates, not a quote. Confirm coverage and out-of-pocket costs with your insurer and provider.
Frequently Asked Questions
How much does Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis cost?
Medicare's national average payment for Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis (CPT 21243) is $1,362.96, with providers billing $14,140.73 on average; state rates run from $1,148.31 to $1,496.04, a meaningful but not extreme spread.
Why do providers charge more than Medicare pays?
Providers set their own chargemaster rates (billed charges), which are typically much higher than what any insurer pays. Medicare pays a fixed rate based on the procedure code and geographic location. The billed charge is relevant mainly for uninsured patients, who may face prices closer to the submitted charge.
How much does Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis cost with insurance?
With commercial insurance, repair of hinged joint of upper and lower jaw bones with prosthesis costs an estimated $3,840.22 on average (range: $2,688.16-$5,376.31), a moderate premium over Medicare's $1,362.96. Without insurance, the estimated cash price is $5,174.49.
Which state has the lowest cost for Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis?
Texas has the lowest average Medicare payment for Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis at $1,148.31, while New York has the highest at $1,496.04 - a meaningful $347.73 spread.
How many providers perform Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis?
Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis is comparatively uncommon: only 71 providers nationally billed Medicare for it in 2023, serving 122 beneficiaries via 139 total services.
What is the billed-to-Medicare markup for Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis?
Providers bill 10.4x what Medicare pays for Repair Of Hinged Joint Of Upper And Lower Jaw Bones With Prosthesis - one of the steepest markups in the catalog at 938% above the Medicare rate.
Related Guides
Tips to reduce out-of-pocket costs
Your right to upfront pricing
How Medicare payments work
Decode charges and codes
Why bills exceed actual costs
Geographic pricing factors
Data from CMS Medicare Physician & Other Practitioners (2023).
Read our methodology - how this data is sourced, computed, and verified.
Related
Every figure on PlainProcedure is rendered directly from CMS Medicare Physician & Other Practitioners data, no number is typed in by an editor. This page draws directly on CMS Medicare Physician & Other Practitioners data, no figure is typed in by an editor. See our editorial standards & corrections policy, the methodology behind these numbers, or report a data error.