CPT 42426 Fee Schedule
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.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Digestive System |
| Common Place of Service | • 21 - Inpatient Hospital • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • LT - Left side of body • RT - Right side of body |
| Complexity Level | High |
| CMS | $1,316.50 Physician Fee Schedule |
National average reimbursement for CPT 42426 by major payers:
$1,831.62
$1,830.22
$1,908.32
$2,253.20
| 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 42426 | ||||||
United | 42426 | $1092.89 | 1013912138 - ALBERT UMBACH | 350593390 - DEACONESS HOSPITAL INC | KY | Surgical Physician Assistant (363AS0400X) |
United | 42426 | $774.00 | 1760445928 - ARIZONA ENDOSCOPY CENTER, LLC | 860908400 - (AZ) ARIZONA ENDOSCOPY CENTER LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $954.00 | 1396823381 - HEAD AND NECK SURGERY ASSOCIATES, PSC, CENTER FOR SURGICAL CARE | 610938951 - HEAD & NECK SURGERY ASSOC., PSC | KY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $525.00 | 1679556864 - DOCTORS GI PARTNERSHIP LTD, HF SURGERY CENTER AT BABCOCK | 593758988 - (FL) DOCTORS GI PARTNERSHIP LTD | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $3742.00 | 1962626523 - CALLOWAY CREEK SURGERY CENTER LP | 141948102 - (TX) CALLOWAY CREEK SURGERY CENTER LP | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $1241.00 | 1750169975 - UNOVA ASC, INC | 812495096 - (FL) UNOVA ASC INC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $8912.00 | 1649534843 - SURGERY CENTER OF WASILLA, LLC | 455023852 - (AK) SURGERY CENTER OF WASILLA LLC | AK | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $2299.00 | 1376634683 - MONTGOMERY SURGICAL CENTER, LTD | 752365748 - (AL) MONTGOMERY SURGICAL CENTER LTD | AL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $1300.00 | 1962661884 - ACD-SA, LTD., SENDERO IMAGING AND TREATMENT CENTER | 742822681 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $2307.00 | 1275292229 - SCOTTSDALE ENDOSCOPY ASC LLC | 873952617 | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $776.00 | 1467582437 - NORTH FLORIDA SURGERY CENTER INC, NORTH FLORIDA SURGERY CENTER | 593377918 - (FL) NORTH FLORIDA SURGERY CENTER INC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $1901.00 | 1578515367 - BLACK CANYON SURGICAL CENTER, LLC | 510514274 - (CO) BLACK CANYON SURGICAL CENTER, LLC | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $3348.22 | 1508213810 - ALEGENT CREIGHTON HEALTH, CHI HEALTH AMBULATORY SURGERY CENTER AT MIDLANDS | 470757164 - ALEGENT CREIGHTON HEALTH | NE | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $1492.00 | 1013138536 - WESTERN WASHINGTON MEDICAL GROUP, INC, PS, DBA: GATEWAY SURGERY CENTER | 911602128 - (WA) WESTERN WASHINGTON MEDICAL GROUP, INC., P.S. | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $2400.00 | 1932214624 - LA PEER SURGERY CENTER, LLC, LA PEER HEALTH SYSTEMS | 202788594 - (CA) LAPEER SURGERY CENTER, LLC | 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 42426 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42426 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 42426 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 |
|---|---|---|
| 42420-CPT | High | Excis Parotid Tumor/Gland;All W Dissec/P |
| 42425-CPT | High | Exc Parotid Total Sacrifice Nerve |
| 42426-CPT | High | Excis Parotid Tumor/Gland All W Unilat R |
| 42510-CPT | Moderate | Creation Of New Drainage Tracts Of Major Saliva Gland Ducts On Both Sides Of Mouth With Tying Of Saliva Gland Ducts Below Both Sides Of Jaw |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42426. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42426 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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