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 |
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 | $1276.00 | 1235178146 - SUBURBAN ENDOSCOPY CENTER, LLC, SUBURBAN ENDOSCOPY CENTER | 820556996 - (NJ) SUBURBAN ENDOSCOPY CENTER LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1258.00 | 1265534556 - SOUTH FLORIDA AMBULATORY SURGICAL CENTER LLC | 651093026 - (FL) SOUTH FLORIDA AMBULATORY SURGI | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $798.00 | 1841286267 - SURGERY CENTER OF SOUTHERN OREGON, LLC | 931189291 - (OR) SURGERY CENTER OF SOUTHERN OREGON, L.L.C. | OR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $699.00 | 1023182581 - MAYS & SCHNAPP PAIN CLINIC & REHABILITATION CENTER | 621512849 - (TN) MAYS SCHNAPP PAIN CLINIC REHABILITATION CENTER | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $781.00 | 1982105458 - HEART CARE CENTER, LLC | 824195385 | MO | 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 | $2580.00 | 1619245230 - AMBULATORY SURGICAL PAVILION AT ROBERT WOOD JOHNSON LLC | 800768614 - (NJ) AMBULATORY SURGICAL PAVILION AT ROBERT WOOD JOHNSON LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1200.00 | 1073578019 - BLUE RIDGE DAY SURGERY CENTER, LP, BLUE RIDGE DAY SURGERY CENTER | 621530122 - (NC) BLUE RIDGE DAY SURGERY CENTER LP | NC | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $454.00 | 1598809758 - CALIFORNIA EYE CLINIC | 680024090 - (CA) CALIFORNIA EYE CLINIC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $825.00 | 1992706840 - AMBULATORY SURGERY CENTER OF BURLEY, LLC | 820502971 - (ID) AMBULATORY SURGERY CENTER OF BURLEY LLC | ID | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $930.00 | 1710177795 - ASPEN SURGERY CENTER, LLC, ASPEN SURGERY CENTER | 205090169 - (CA) ASPEN SURGERY CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1727.00 | 1083715148 - ASC SURGICAL VENTURES, LLC, OSMC OUTPATIENT SURGERY CENTER | 351995261 | IN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $1347.00 | 1770731853 - SHAWNEE MISSION PRAIRIE STAR SURGERY CENTER LLC, ADVENTHEALTH SURGERY CENTER LENEXA | 364634843 - (KS) SHAWNEE MISSION PRAIRIE STAR SURGERY CENTER LLC | KS | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42100 | $2483.00 | 1710114293 - RIVERVIEW SURGERY CENTER AT THE NAVY YARD LP | 263910345 - (PA) RIVERVIEW SURGERY CENTER AT THE NAVY YARD LP | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
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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