No office rate
Choose 21385 for a transantral repair through the maxillary sinus. Choose 21386 when the repair uses a periorbital approach.
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CMS RVU26D · Effective 2026-10-01
21385 Orbital fracture repair Medicare reimbursement rates in Vermont
Reports open repair of an orbital fracture through the maxillary sinus, with the transantral route documented in the operative report. Compare 21385 office and facility rates across CMS payment localities in Vermont.
Amounts below use the non-QP conversion factor for participating physicians. These are base physician payments before claim-level adjustments, not patient costs or total hospital charges.
What does Medicare pay for 21385 in Vermont?
Vermont has 1 payment locality in this comparison. Use the service location to choose the applicable amount. These are the supported base rates for the payment area shown below, using the same CMS release.
Office / nonfacility
No supported rate
Facility setting
$642.77
1 of 1 localities have a supported rate.
Payment area: Vermont
One mapped payment locality.
These are locality ranges, not averages or address-specific quotes. A facility-setting amount covers the physician service; it does not include a hospital’s separate bill. Choose a locality below to inspect its calculation, compare other payment areas, or price a percentage of Medicare.
Orbital fracture surgery
About 21385: Orbital fracture repair, transantral approach
Reports open repair of an orbital fracture through the maxillary sinus, with the transantral route documented in the operative report.
This service repairs an orbital fracture by reaching the orbit through the maxillary sinus. The surgeon exposes the fracture from below, repositions displaced bone as needed, and may use a temporary balloon to support the repair. It is generally performed by a surgeon treating facial or orbital trauma in an operating room. The operative report should identify the fracture and describe the transantral route and repair performed.
Select this code when the repair is performed through the sinus rather than through a periorbital incision or a combined route. The 90-day global period includes the day-before preoperative visit and 90 days of related postoperative care. In a same-session multiple-procedure case, the highest-valued procedure is paid in full and additional procedures at 50%. Bilateral reporting with modifier 50 is paid at 150%. Assistant-at-surgery payment may be made; co-surgeon payment requires supporting documentation, and team-surgery payment is not permitted.
CMS billing rules for 21385
- Global period
- Major surgery with a 90-day global period: the day-before preoperative visit and 90 days of related postoperative care are included.
- Multiple procedures
- Standard multiple procedure reduction: the highest-valued procedure is paid in full and others at 50% when performed in the same session.
- Bilateral procedures
- Bilateral procedure with modifier 50 is paid at 150%.
- Assistant at surgery
- Assistant at surgery may be paid.
- Co-surgeons
- Co-surgeons paid only with supporting documentation.
- Team surgery
- Team surgery not permitted.
Where the value comes from
- Work RVU9.33 · 46%
- Practice expense (office) RVU9.13 · 45%
- Malpractice RVU1.73 · 9%
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
21385 compared with similar codes
Office rates for Vermont, from the same CMS release.
No office rate
21387 represents a combined periorbital and transantral approach; 21385 is the transantral approach.
No office rate
21390 describes a periorbital repair with an implant. The approach and implant detail distinguish it from 21385.
No office rate
21395 describes a periorbital repair with a graft. Use 21385 for the transantral approach.
Compare 21385 by payment locality
Find the payment area for your service address, then open its rate page for calculation inputs, release history and the percentage-of-Medicare tool. A city may cross payment-area boundaries; the ZIP lookup above helps resolve the location.
1 of 1 payment localities
Vermont →
Office / nonfacility
Unavailable
Facility
$642.77
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How this local rate is calculated
Each RVU component is multiplied by its own geographic practice cost index (GPCI). The three adjusted components are added, then multiplied by the conversion factor. These are the inputs used for 21385 in Vermont.
PPRRVU2026_Oct_nonQPP.csv
1,964
- Code
- 21385
- Physician work
- 9.33
- Practice expense
- 9.13
- Malpractice
- 1.73
GPCI2026.csv
105
- Locality
- Vermont
- Physician work
- 1.000
- Practice expense
- 0.990
- Malpractice
- 0.506
| Component | RVU | Locality factor | Adjusted |
|---|---|---|---|
| Physician work | 9.33 | × 1.000 | 9.3300 |
| Practice expense | 9.13 | × 0.990 | 9.0387 |
| Malpractice | 1.73 | × 0.506 | 0.8754 |
| Total RVUs | 19.2441 | ||
| Conversion factor | × 33.4009 | ||
Facility rate, Vermont$642.77
Explore RVUs, geographic factors and the full formula
Facility
| Component | RVU | Local GPCI |
|---|---|---|
| Work | 9.33 | 1 |
| Practice expense | 9.13 | 0.99 |
| Malpractice | 1.73 | 0.506 |
(9.33 × 1 + 9.13 × 0.99 + 1.73 × 0.506) × $33.4009 = $642.77
The office and facility calculations use their respective practice-expense RVUs. The facility amount here is the physician fee, not a separate hospital or facility bill.
21385 billing questions
How is 21385 distinguished from 21386?
Use 21385 when the orbital fracture is repaired through the maxillary sinus. Code 21386 describes a periorbital approach.
Is balloon placement separately reported?
A temporary balloon placed as part of the transantral fracture repair is included in this service and is not separately reported as an additional procedure.
Can modifier 50 be used for bilateral repairs?
Yes. CMS lists bilateral reporting with modifier 50 and pays the procedure at 150%.
What documentation supports this code?
Document the orbital fracture, the operative repair, and the transantral route. The note should make clear that the repair was performed through the maxillary sinus.
How are other procedures in the same session paid?
Under the standard multiple-procedure reduction, the highest-valued procedure is paid in full and other procedures are paid at 50%. The code has a 90-day global period.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense, and malpractice RVUs, adjusted by each locality’s geographic indices and the applicable conversion factor. Unavailable or separately priced services are labeled rather than assigned a made-up amount.
Source: RVU26D. Effective 2026-10-01 through the day before 2027-01-01.
1,96121360,,Opn tx dprsd malar fracture,A,,7.01,5.98,NA,5.98,,1.04,14.03,14.03,0,090,0.10,0.69,0.21,2,1,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,96221365,,Opn tx complx malar fx,A,,16.35,9.88,NA,9.88,,2.59,28.82,28.82,0,090,0.10,0.69,0.21,2,1,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,96321366,,Opn tx complx malar w/grft,A,,18.14,12.59,NA,12.59,,3.36,34.09,34.09,0,090,0.10,0.69,0.21,2,1,2,2,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,96421385,,Opn tx orbit fx transantral,A,,9.33,9.13,NA,9.13,,1.73,20.19,20.19,0,090,0.10,0.69,0.21,2,1,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,96521386,,Opn tx orbit fx periorbital,A,,9.33,7.83,NA,7.83,,1.73,18.89,18.89,0,090,0.10,0.69,0.21,2,1,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,96621387,,Opn tx orbit fx combined,A,,9.86,9.33,NA,9.33,,1.83,21.02,21.02,0,090,0.10,0.69,0.21,2,1,2,0,0,9,,33.4009,09,0,99,0.00,0.00,0.00
1,96721390,,Opn tx orbit periorbtl implt,A,,10.95,8.79,NA,8.79,,1.47,21.21,21.21,0,090,0.10,0.69,0.21,2,1,2,1,0,9,,33.4009,09,0,99,0.00,0.00,0.00
10204412,TX,18,HOUSTON,1.008,0.993,1.376
10304412,TX,99,REST OF TEXAS,1.000,0.949,0.903
10403502,UT,09,UTAH,1.000,0.940,0.898
10514512,VT,50,VERMONT,1.000,0.990,0.506
10611302,VA,00,VIRGINIA,1.000,0.983,0.706
10709202,VI,50,VIRGIN ISLANDS,1.000,1.011,0.985
10802402,WA,02,SEATTLE (KING CNTY),1.050,1.227,0.817