Rate Benchmarking
Compare your rates with similar providers.
Select a published rate, define comparable providers, and see where that rate falls in your market.
See a sample rate comparisonCPT 42260 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.
Repair Fistula Nasolabial
| 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 59 - Distinct Procedural Service |
| Complexity Level | High |
| Medicare Fee Schedule | $852.73 national non-facility rate (2026) · View Medicare rates for 42260 |
| Medicaid Fee Schedule | $681.535 median of the 8 states in the free preview · View Medicaid rates for 42260 |
National average reimbursement for CPT 42260 by major payers:
$1,034.00
$1,099.75
$1,177.49
$1,096.79
Compare published rates across providers.
Choose a payer to see a sample of rates for CPT 42260.
CPT 42260
5 of 25 sample ratesHigher to lower in this preview
Saint Francis Surgery Center, LLC, Saint Francis Surgery Center
Saint Francis Surgery Center LLC
$3,752.00Published rateCrystal Cities Surgery Center, Twin Cities Surgery Center
$2,206.00Published rateSurgery Center Of Athens LLC
$1,652.00Published rateSunset Pain Surgery Center
$1,100.00Published ratePremier Endoscopy Center LLC
$383.00Published rate
Get a free rate benchmark for your specialty.
Choose your state and specialty to build a report from payer-published rates.
Use market rates to prepare your payer proposal.
Payer Contract Negotiation
Draft a fee schedule renegotiation letter.
Use your fee schedule and market benchmarks to set target rates and draft a letter for your payer.
See a sample payer proposalCPT 42260 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42260 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 42260 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 |
|---|---|---|
| 42260-CPT | High | Repair Fistula Nasolabial |
| 42600-CPT | Moderate | Close Salivary Fistula |
| 42650-CPT | Low | Dilate Salivary Duct |
| 42660-CPT | Low | Dilation And Catheterization, Dilation And Catheterization Of Salivary Duct With Orwithout Injection Dilation And Catheterization Of Salivary Duct With Or |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42260. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42260 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.
FREE SAMPLE MARKET COMPARISON
Let's review your payer contracts side-by-side with the market.
Bring your top codes (like CPT 42260) and we'll show you how you compare in 15 minutes or less.