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See a sample rate comparisonCPT 42104 Fee Schedule
Last Verified: October 2026
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.
Surgery To Remove Mouth Tumor, Surgery To Remove A Tumor From The Roof Of The Mouth. The Procedure Involves The Uvula At The Back Of The Mouth.
| 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 | 51 - Multiple procedures 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $218.44 national non-facility rate (2026) · View Medicare rates for 42104 |
| Medicaid Fee Schedule | $171.175 median of the 8 states in the free preview · View Medicaid rates for 42104 |
National average reimbursement for CPT 42104 by major payers:
$256.47
$278.41
$301.68
$234.74
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CPT 42104
5 of 25 sample ratesHigher to lower in this preview
Surgery Center Of Southwest Ohio, LLC, The Surgery Center Of Southwest Ohio
The Surgery Center Of Southwest
$5,469.00Published rateLeonardtown Surgery Center LLC
Leonardtown Surgery Center, LLC
$1,258.00Published rateLutherville Surgery Center, LLC
Lutherville Surgery Center LLC
$788.00Published rateAmbulatory Surgery Center LLC, Ambulatory Surgery Center
Ambulatory Surgery Center LLC
$615.00Published rateSt Johns Surgery Center LLC
$343.00Published rate
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See a sample payer proposalCPT 42104 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42104 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 42104 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 |
|---|---|---|
| 42104-CPT | Moderate | Surgery To Remove Mouth Tumor, Surgery To Remove A Tumor From The Roof Of The Mouth. The Procedure Involves The Uvula At The Back Of The Mouth. |
| 42106-CPT | Moderate | Surgery To Remove Mouth Tumor, Surgery To Remove A Tumor From The Roof Of The Mouth. The Procedure Involves The Uvula At The Back Of The Mouth. |
| 42107-CPT | Moderate | Surgery To Remove Mouth Tumor, Surgery To Remove A Tumor From The Roof Of The Mouth. The Procedure Involves The Uvula At The Back Of The Mouth. |
| 42160-CPT | Moderate | Treat Abnormal Tissue In Mouth, Treatment Or Removal Of Abnormal Tissue (Lesion) Located On The Roof Of The Mouth Or Uvula By Burning Freezing Or The Use Of Chemicals. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42104. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42104 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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