CPT 42100 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Digestive System |
| Common Place of Service | • 11 - Office • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • 51 - Multiple procedures • GC - Service performed by resident under supervision |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 42100 |
National average reimbursement for CPT 42100 by major payers:
$184.32
$195.30
$209.99
$245.52
| 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 42100 | ||||||
United | 42100 | $396.00 | 1053345082 - EYE SURGERY LIMITED LLC, VIRGINIA CENTER FOR EYE SURGERY | 522406179 - (VA) EYE SURGERY LIMITED, LLC | VA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1000.00 | 1225439250 - ADVANCED SURGERY CENTER OF SAN ANTONIO, LLC | 465742281 - (TX) ADVANCED SURGERY CENTER OF SAN ANTONIO, LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $725.00 | 1194245951 - PSG SURGERY CENTER LLC, SURGERY CENTER OF AMARILLO | 821476685 - (TX) PSG SURGERY CENTER LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1850.00 | 1508276080 - OHIO SPECIALTY SURGICAL SUITES, LLC | 464078247 - (OH) OHIO SPECIALTY SURGICAL SUITES LLC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $420.00 | 1790172922 - YUMA VALLEY AMBULATORY PAIN SERVICES INC | 471779727 - (AZ) YUMA VALLEY AMBULATORY PAIN SERVICES INC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $654.00 | 1952518029 - RALEIGH NC ENDOSCOPY ASC LLC, RALEIGH ENDOSCOPY CENTER - CARY | 200864597 - (NC) RALEIGH NC ENDOSCOPY ASC LLC | NC | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1200.00 | 1992259337 - ADVOCATE CONDELL AMBULATORY SURGERY CENTER, LLC | 475337115 - (IL) ADVOCATE CONDELL AMBULATORY SURGERY CENTER LLC | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $794.00 | 1609537992 - NCH BONITA AMBULATORY SURGERY CENTER, LLC | 873854125 - (FL) NCH BONITA AMBULATORY SURGERY CENTER LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1666.00 | 1114965803 - ADVANCED ENDOSCOPY & SURGICAL CENTER LLC, ADVANCED ENDOSCOPY & SURGICAL CENTER | 113660090 - (NJ) ADVANCED ENDOSCOPY SURGICAL CENTER LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $262.02 | 1851736268 - STEVEN VONFROLIO | 350593390 - DEACONESS HOSPITAL INC | IN | Hospitalist Physician (208M00000X) |
United | 42100 | $690.00 | 1073663480 - DOCTORS CLINIC A PROFESSIONAL CORPORATION, THE DOCTORS CLINIC AMBULATORY SURGERY CENTER | 911939739 - FRANCISCAN MEDICAL GROUP | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1558.00 | 1477516961 - CENTRUM SURGERY CENTER LTD | 752546712 - (CO) CENTRUM SURGERY CENTER LTD | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $575.00 | 1376729715 - ENDOSCOPY ASSOCIATES OF VALLEY FORGE, LLC | 161770779 - (PA) ENDOSCOPY ASSOCIATES OF VALLEY FORGE LLC | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $120.38 | 1851575476 - MARTIN KELLY | 350593390 - DEACONESS HOSPITAL INC | AR | Certified Registered Nurse Anesthetist (367500000X) |
United | 42100 | $700.00 | 1952363368 - GOLDEN TRIANGLE SURGICENTER LP | 330529450 - (CA) GOLDEN TRIANGLE SURGICENTER LP | CA | 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 42100 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42100 code is part of the Surgery services used for Surgical Procedures on the Digestive 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 42100 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 |
|---|---|---|
| 41019-CPT | Moderate | Placement Of Needles Catheters Or Other Device(S) Into The Head And/Or Neck Region (Percutaneous Transoral Or Transnasal) For Subsequent Interstitial Radioelement Application |
| 41100-CPT | Moderate | Biopsy Tongue; Anterior Two-Thirds |
| 41800-CPT | Moderate | Drain Lesion Dentoalveolar |
| 42100-CPT | Low | Biopsy Palate Uvula |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42100. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42100 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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