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 |
| CMS | $232.90 Physician Fee Schedule |
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 | $1762.00 | 1083384432 - NASHVILLE SURGICENTER, LLC | 474086590 - (TN) NASHVILLE SURGICENTER LLC | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $178.00 | 1316492416 - DANA SPIVEY | 350593390 - DEACONESS HOSPITAL INC | IN | Acute Care Nurse Practitioner (363LA2100X) |
United | 42806 | $1200.00 | 1922531268 - AMERICAN ACCESS CARE OF BALTIMORE ASC LLC | 814584087 - (MD) AMERICAN ACCESS CARE OF BALTIMORE ASC LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $1646.00 | 1366868572 - PREMIER SURGERY CENTER, LLC | 463321793 - (NC) PREMIER SURGERY CENTER LLC | NC | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $496.00 | 1326444688 - BRYAN COLLEGE STATION ASC, LP, THE HEART AND VASCULAR SURGERY CENTER | 471615354 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
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 | $1100.00 | 1932155470 - SUSQUEHANNA SURGERY CENTER INC | 233046101 - (PA) SUSQUEHANNA SURGERY CENTER INC | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $806.00 | 1033466933 - TOWN CENTER ASC LLC | 453062883 - (MI) TOWN CENTER ASC LLC | MI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $1561.00 | 1356903967 - UNITY LINDEN OAKS SURGERY CENTER | 800798208 | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $1220.00 | 1376650911 - ELM PLACE AMBULATORY SURGICAL CENTER | 752142438 - (TX) ELM PLACE AMBULATORY SURGICAL CENTER | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $1326.00 | 1851678981 - RIDGECREST SPECIALTY SURGERY CENTER, A PROFESSIONAL CORPORATION | 453602999 - (CA) RIDGECREST SPECIALTY SURGERY CENTER A PROFESSIONAL CORPORATION | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $387.41 | 1972593572 - ANDREW PARKER | 350593390 - DEACONESS HOSPITAL INC | IN | Anesthesiology Physician (207L00000X) |
United | 42806 | $496.00 | 1902851009 - 90210 SURGERY MEDICAL CENTER, LLC, 90210 SURGERY MEDICAL CENTER AT LINDEN | 134341801 - (CA) 90210 SURGERY MEDICAL CENTER | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $496.00 | 1528572815 - SUN SURGERY CENTER HUNTINGTON LLC | 822382700 - (CA) SUN SURGERY CENTER HUNTINGTON LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42806 | $496.00 | 1316949415 - NEWPORT BEACH SURGERY CENTER, LLC, NEWPORT BEACH SURGERY CENTER | 330488134 - (CA) NEWPORT BEACH 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 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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