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See a sample rate comparisonCPT 42800 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.
Biopsy; Oropharynx
| Key Fact | Detail |
|---|---|
| Service Type | Surgery Surgical Procedures on the Digestive System |
| Common Place of Service | 11 - Office 22 - On Campus Outpatient Hospital |
| Common Modifiers | 51 - Multiple procedures 59 - Distinct Procedural Service |
| Complexity Level | Low |
| Medicare Fee Schedule | $159.66 national non-facility rate (2026) · View Medicare rates for 42800 |
| Medicaid Fee Schedule | $124.775 median of the 8 states in the free preview · View Medicaid rates for 42800 |
National average reimbursement for CPT 42800 by major payers:
$199.81
$207.58
$226.44
$197.17
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CPT 42800
5 of 25 sample ratesHigher to lower in this preview
Baylor Surgicare At North Dallas, LLC, Baylor Scott & White Surgicare-North Dallas
$2,172.00Published rateAdvanced Surgery Center Of Tampa, LLC
$934.00Published rateSunset Surgical Centre LLC
$540.00Published rateShadyside Surgi-Center, Inc.
Shadyside Surgicenter Inc
$314.00Published rateDiane Hancock
Deaconess Hospital Inc
$126.79Published rate
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See a sample payer proposalCPT 42800 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42800 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 42800 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.
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42800. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42800 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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