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See a sample rate comparisonCPT 42220 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 For Cleft Palate, Surgery To Close An Opening In The Roof Of The Mouth (Cleft Palate). The Procedure Includes Reconstructing The Natural Shape Of The Mouth. A Graft May Be Used.
| 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 | GC - Service performed by resident under supervision 51 - Multiple procedures |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $539.43 national non-facility rate (2026) · View Medicare rates for 42220 |
| Medicaid Fee Schedule | $433.50 median of the 8 states in the free preview · View Medicaid rates for 42220 |
National average reimbursement for CPT 42220 by major payers:
$731.23
$762.76
$821.26
$931.54
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CPT 42220
5 of 25 sample ratesHigher to lower in this preview
Roc Surgery LLC, Riley Outpatient Surgery Center
Roc Surgery LLC
$11,291.00Published rateNew Jersey Surgery Center LLC, New Jersey Surgery Center
New Jersey Surgery Center LLC
$5,435.00Published rateCapital Endoscopy LLC
Capital Endoscopy & Surgery Center
$3,486.00Published rateEndoscopy Center Of Santa Maria Inc, The Endoscopy Center Of Santa Maria, Inc.
Endoscopy Center Of Santa Maria, Inc.
$2,350.00Published rateBergen Gastroenterology PC
Bergen Gastroenterology, P.C.
$705.00Published rate
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See a sample payer proposalCPT 42220 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42220 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 42220 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 |
|---|---|---|
| 42182-CPT | Moderate | Repair Laceration Of Palate, Repair Laceration Of Palate Over 2 Cm Or Complexrepair Laceration Of Palate Over 2 Cm Or Complex |
| 42200-CPT | High | Surgery For Cleft Palate, Surgery To Close An Opening In The Roof Of The Mouth (Cleft Palate). The Procedure Includes Reconstructing The Natural Shape Of The Mouth. A Graft May Be Used. |
| 42210-CPT | High | Surgery For Cleft Palate, Surgery To Close An Opening In The Roof Of The Mouth (Cleft Palate). The Procedure Includes Reconstructing The Natural Shape Of The Mouth. A Graft May Be Used. |
| 42220-CPT | Moderate | Surgery For Cleft Palate, Surgery To Close An Opening In The Roof Of The Mouth (Cleft Palate). The Procedure Includes Reconstructing The Natural Shape Of The Mouth. A Graft May Be Used. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42220. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42220 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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