CPT 42215 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 | • 22 - On Campus Outpatient Hospital • 21 - Inpatient Hospital |
| Common Modifiers | • None • 51 - Multiple procedures • AS - PA/NP/CNS assistant at surgery |
| Complexity Level | Moderate |
| CMS | $688.98 Physician Fee Schedule |
National average reimbursement for CPT 42215 by major payers:
$918.53
$956.12
$1,029.59
$1,179.31
| 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 42215 | ||||||
United | 42215 | $3730.00 | 1528104080 - SURGICAL CENTER AT CEDAR KNOLLS LLC | 202158771 - (NJ) SURGICAL CENTER AT CEDAR KNOLLS | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $1500.00 | 1316905680 - OHIO EYE SURGERY CENTER | 311327699 - (OH) OHIO EYE SURGERY CENTER | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $3708.00 | 1073794855 - SURGICARE OF LA VETA INC., BARRANCA SURGERY CENTER | 752507129 | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $580.19 | 1386650927 - BETHANY BURKHART-EDELEN | 350593390 - DEACONESS HOSPITAL INC | KY | Emergency Medicine Physician (207P00000X) |
United | 42215 | $3810.00 | 1770958522 - UCHEALTH AMBULATORY SURGERY CENTERS, LONGS PEAK SURGERY CENTER, LLC | 383984888 - (CO) UCHEALTH AMBULATORY SURGERY CENTERS | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $5433.00 | 1063099190 - ASCENSION SAINT THOMAS LEBANON SURGERY CENTER LLC, LEBANON SURGERY CENTER | 862679471 | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $4781.00 | 1568867075 - POTOMAC VIEW SURGERY CENTER, LLC | 471352116 - (MD) POTOMAC VIEW SURGERY CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $1636.00 | 1578515995 - RAND SURGICAL PAVILLION CORP | 650156637 - (FL) RAND SURGICAL PAVILLION CORP | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $1786.00 | 1336366442 - CASTLE HILLS OUTPATIENT CENTER, INC., SURGICAL ARTS CENTER | 742931255 - (TX) CASTLE HILLS OUTPATIENT CENTER INC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $3028.00 | 1932285111 - ORTHOVIRGINIA OPERATORY | 540885859 - (VA) ORTHOVIRGINIA, INC. | VA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $7121.00 | 1710910922 - SURGERY CENTER OF INDEPENDENCE LP | 200670748 - (MO) SURGERY CENTER OF INDEPENDENCE LP | MO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $5020.00 | 1235146325 - WEBSTER AMBULATORY SURGERY CENTER LP, WEBSTER SURGERY CENTER | 205953387 | MO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $3177.00 | 1124492996 - MOHS AND SKIN SURGERY CENTER, LLC | 474284353 - (MD) MOHS AND SKIN SURGERY CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $3249.00 | 1437250248 - GEORGIA SURGICAL CENTER ON PEACHTREE, LLC | 582394271 - (GA) GEORGIA SURGICAL CENTER ON PEACHTREE LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42215 | $2600.00 | 1629313739 - COLTON CA MULTI ASC LP, PREMIER OUTPATIENT SURGERY CENTER | 461462978 - (CA) COLTON CA MULTI ASC 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 42215 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42215 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 42215 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 |
|---|---|---|
| 42205-CPT | High | Palatoplasty W Closure Alveol Ridge |
| 42210-CPT | High | Palatoplasty For Cleft Palate, With Closure Of Alveolar Ridge; With Bone Graft To Alveolar Ridge (Includes Obtaining Graft) |
| 42215-CPT | Moderate | Palatoplasty Major |
| 42220-CPT | Moderate | Palatoplasty Cleft Palate;2ndary Lengthe |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42215. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42215 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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