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See a sample rate comparisonCPT 42281 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.
Insert Prosthesis Palate Pin Type
| 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 AS - PA/NP/CNS assistant at surgery |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $241.49 national non-facility rate (2026) · View Medicare rates for 42281 |
| Medicaid Fee Schedule | $188.835 median of the 8 states in the free preview · View Medicaid rates for 42281 |
National average reimbursement for CPT 42281 by major payers:
$272.08
$284.55
$302.75
$263.60
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CPT 42281
5 of 25 sample ratesHigher to lower in this preview
Aurora Surgery Centers, LLC
Aurora Surgery Centers LLC
$3,024.00Published rateWinter Haven Ambulatory Surgical Center LLC
Winter Haven Ambulatory Surgical Center, LLC
$1,258.00Published rateWarren Gastro Endoscopy Ctr Inc
$703.00Published rateGalleria Surgery Center LLC
$500.00Published rateCynthia Lewis
Deaconess Hospital Inc
$183.97Published rate
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Payer Contract Negotiation
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See a sample payer proposalCPT 42281 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42281 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 42281 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 |
|---|---|---|
| 42280-CPT | Moderate | Maxillary Impression For Palatal Prosthe |
| 42281-CPT | Moderate | Insert Prosthesis Palate Pin Type |
| 42299-CPT | High | Surgery On Uvula Or Palate, Surgery Performed On The Uvula Or The Roof Of The Mouth (Palate). |
| 42400-CPT | Low | Saliva Gland Biopsy, A Procedure To Remove A Sample Of Tissue From A Saliva Gland For Testing (Biopsy). The Sample May Be Taken In A Surgery Or With A Needle. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42281. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42281 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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