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See a sample rate comparisonCPT 42804 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; Nasopharynx Visible Lesion Simpl
| Key Fact | Detail |
|---|---|
| Service Type | Surgery Surgical Procedures on the Digestive System |
| Common Place of Service | 22 - On Campus Outpatient Hospital 11 - Office |
| Common Modifiers | 51 - Multiple procedures 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $215.44 national non-facility rate (2026) · View Medicare rates for 42804 |
| Medicaid Fee Schedule | $169.02 median of the 8 states in the free preview · View Medicaid rates for 42804 |
National average reimbursement for CPT 42804 by major payers:
$250.83
$262.11
$288.64
$203.31
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CPT 42804
5 of 25 sample ratesHigher to lower in this preview
Pacific Surgery Center, LLC
Pacific Surgery Center LLC
$2,933.18Published rateNorth Florida Regional Freestanding Surgery Center Lp
$978.00Published rateTemecula Ca United Surgery Center, Lp
Temecula Ca United Surgery Cen
$799.00Published rateCopper City Surgery Center, PLLC
Copper City Surgery Center PLLC
$600.00Published rateZachary Asc Partners, LLC, Zachary Asc Partners, LLC
Zachary Asc Partners LLC
$315.00Published rate
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See a sample payer proposalCPT 42804 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42804 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 42804 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 |
|---|---|---|
| 42804-CPT | Moderate | Biopsy; Nasopharynx Visible Lesion Simpl |
| 42970-CPT | Moderate | Control Of Nasopharyngeal Hemo, Control Of Nasopharyngeal Hemorrhage Primary Or Secondary(Eg Postadenoidectomy) Simple With Posterior Nasal Packs With Or Without Anterior Packsandor Cauterization |
| 42971-CPT | Moderate | Control Nose Throat Bleeding, Control Of Nasopharyngeal Hemorrhage Primary Or Secondary Eg Postadenoidectomy Complicated Requiring Hospitalization |
| 42972-CPT | Moderate | Control Nose Throat Bleeding, Control Of Nasopharyngeal Hemorrhage Primary Or Secondary Eg Postadenoidectomy With Secondary Surgical Intervention |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42804. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42804 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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