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 |
| Medicare Fee Schedule | View Medicare rates for 42426 |
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 | $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 | $557.00 | 1871526004 - THE SKIN CANCER CENTER, INC. | 200438144 - (OH) THE SKIN CANCER CENTER INC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $1092.89 | 1962919738 - HEATHER MELLISH | 350593390 - DEACONESS HOSPITAL INC | FL | Certified Registered Nurse Anesthetist (367500000X) |
United | 42426 | $5379.00 | 1770252868 - STONESPRINGS SURGICENTER, LLC | 812929320 - (VA) STONESPRINGS SURGICENTER LLC | VA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $1391.00 | 1437101433 - TRI CITY SURGERY CENTER LLC | 201504745 - (AZ) TRI-CITY SURGERY CENTER LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $2353.00 | 1215492061 - ADVANCED SPINE CENTER OF WISCONSIN, LLC | 832438541 - (WI) ADVANCED SPINE CENTER OF WISCONSIN | WI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $2388.00 | 1891257473 - WESTGATE SURGERY CENTER, LLC, WESTGATE SURGERY CENTER | 352651945 - (AZ) WESTGATE SURGERY CENTER LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $2865.00 | 1669446852 - VOORHEES NJ ENDOSCOPY ASC LLC, THE ENDO CENTER AT VOORHEES | 510446274 - (NJ) THE VOORHEES NJ ENDOSCOPY ASC LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $4825.00 | 1215061049 - PRESBYTERIAN SAMEDAY SURGERY CENTER AT BALLANTYNE LLC, NOVANT HEALTH BALLANTYNE OUTPATIENT SURGERY | 203135052 | NC | 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 | $4141.00 | 1023316197 - NORTH DALLAS SURGICAL CENTER,LLC, TEXAS HEALTH SURGERY CENTER ADDISON | 272248103 - (TX) NORTH DALLAS SURGICAL CENTERLLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $751.00 | 1528680865 - MERIDIAN SURGERY CENTER LLC | 845179604 - (MD) MERIDIAN SURGERY CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $2378.63 | 1548379738 - TEODORA BOTEZ | 350593390 - DEACONESS HOSPITAL INC | IN | Anesthesiology Physician (207L00000X) |
United | 42426 | $1900.00 | 1912362955 - ST CHARLES SURGICAL CENTER | 474573964 - (CA) ST CHARLES SURGICAL CENTER | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42426 | $3150.00 | 1093383655 - SHERMAN ENDOSCOPY CENTER, LLC | 861402910 - (TX) SHERMAN ENDOSCOPY CENTER LLC | TX | 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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