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See a sample rate comparisonCPT 42226 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address high-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 | 51 - Multiple procedures GC - Service performed by resident under supervision |
| Complexity Level | High |
| Medicare Fee Schedule | $834.69 national non-facility rate (2026) · View Medicare rates for 42226 |
| Medicaid Fee Schedule | $677.365 median of the 8 states in the free preview · View Medicaid rates for 42226 |
National average reimbursement for CPT 42226 by major payers:
$1,202.30
$1,203.83
$1,301.73
$1,483.52
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CPT 42226
5 of 25 sample ratesHigher to lower in this preview
Canonsburg General Hospital
Highmark Health
$16,282.82Published ratePrescott Outpatient Surgical Center LLC
Prescott Outpatient Surgical Center, Lp
$5,354.00Published rateMedstar Surgery Center At Lafayette Centre, LLC
Medstar Surgery Center At Lafayette Centre LLC
$3,486.00Published rateParkhill Surgery Center Plano, LLC
$2,738.00Published ratePiedmont Day Surgery Center Inc
$1,547.00Published rate
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See a sample payer proposalCPT 42226 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42226 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 42226 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 |
|---|---|---|
| 42225-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. |
| 42226-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. |
| 42227-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. |
| 42235-CPT | Moderate | Repair Anterior Palate Including Vomer F |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42226. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42226 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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