CPT 42806 Fee Schedule
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.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Digestive System |
| Common Place of Service | • 22 - On Campus Outpatient Hospital • 24 - Ambulatory Surgical Center |
| Common Modifiers | • None • 51 - Multiple procedures • 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 42806 |
National average reimbursement for CPT 42806 by major payers:
$279.09
$294.80
$317.58
$380.99
| 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 42806 | ||||||
United | 42806 | $889.00 | 1114907920 - MIAMI ASC LP, THE ENDOSCOPY CENTER | 621600424 - (FL) MIAMI ASC LP | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $496.00 | 1295403426 - DRS LLC, MCMINNVILLE SURGERY CENTER | 320613056 - (OR) DRS LLC | OR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $496.00 | 1780752352 - PREMIER SURGERY CENTER OF SANTA MARIA LLC | 203502741 - (CA) PREMIER SURGERY CENTER OF SANTA MARIA, INC. | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $904.00 | 1023343720 - HATTIESBURG SURGERY CENTER, LLC | 263789784 - (MS) HATTIESBURG SURGERY CENTER LLC | MS | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $178.00 | 1821721739 - CAROLYN COLE | 350593390 - DEACONESS HOSPITAL INC | IN | Medical Physician Assistant (363AM0700X) |
United | 42806 | $1500.00 | 1750521720 - SPOKANE VALLEY EAR NOSE & THROAT PS, SPOKANE VALLEY AMBULATORY SURGERY CENTER | 911072626 - (WA) SPOKANE VALLEY EAR, NOSE & THROAT, P.S. | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $2069.00 | 1598039125 - ROOSEVELT SURGERY CENTER, LLC | 271778024 - (NY) ROOSEVELT SURGERY CENTER, LLC | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $1150.00 | 1629443478 - SCOTTSDALE MCCORMICK RANCH SURGICENTER LLC | 475123911 - (AZ) SCOTTSDALE MCCORMICK RANCH SURGICENTER | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $392.54 | 1053356436 - EDGEWORTH COMMONS GROUP LLC, SURGERY CENTER AT EDGWORTH COMMONS | 20713415 - (PA) EDGEWORTH COMMONS GROUP LLC | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $387.41 | 1477582930 - SHIRISHKUMAR PATEL | 350593390 - DEACONESS HOSPITAL INC | KY | Internal Medicine Physician (207R00000X) |
United | 42806 | $586.00 | 1518998764 - TENNESSEE PAIN SURGERY CENTER, LLC | 621790133 - (TN) TENNESSEE PAIN SURGERY CENTER LLC | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $3348.22 | 1578208435 - NPI SURGERY CENTER LLC | 852578527 - (NE) NPI SURGERY CENTER LLC | NE | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $2003.00 | 1497068761 - CARNEGIE HILL ENDOSCOPY LLC | 270385539 - (NY) CARNEGIE HILL ENDOSCOPY LLC | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $6245.00 | 1730212879 - TEXAS HEALTH HARRIS METHODIST HOSPITAL SOUTHWEST FORT WORTH | 752678857 - (TX) TEXAS HEALTH HARRIS METHODIST HOSPITAL SOUTHWEST FORT WORTH | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $1569.00 | 1689633588 - SOUTH JERSEY ENDOSCOPY LLC, DIMARINO-KROOP-PRIETO GI ASSOC | 200478348 - (NJ) SOUTH JERSEY ENDOSCOPY LLC | NJ | 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 42806 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42806 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 42806 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 |
| 42806-CPT | Moderate | Biopsy Nasopharynx Survey |
| 42970-CPT | Moderate | Control Of Nasopharyngeal Hemorrhage, Primary Or Secondary (Eg, Postadenoidectomy); Simple, With Posterior Nasal Packs, With Or Without Anterior Packs And/Or Cautery |
| 42971-CPT | Moderate | Control Of Nasopharyngeal Hemorrhage (Primary Or Secondary, Eg, Postadenoidectomy); Complicated, Requiring Hospitalization |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42806. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42806 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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