Rate Benchmarking
Compare your rates with similar providers.
Select a published rate, define comparable providers, and see where that rate falls in your market.
See a sample rate comparisonCPT 42815 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.
Excision Branchial Cleft Cyst, Excision Branchial Cleft Cyst Vestige Or Fistulaextending Beneath Subcutaneous Tissues Andor Into Pharynx
| 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 | RT - Right side of body LT - Left side of body |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $478.30 national non-facility rate (2026) · View Medicare rates for 42815 |
| Medicaid Fee Schedule | $386.81 median of the 8 states in the free preview · View Medicaid rates for 42815 |
National average reimbursement for CPT 42815 by major payers:
$735.54
$736.65
$793.30
$894.57
Compare published rates across providers.
Choose a payer to see a sample of rates for CPT 42815.
CPT 42815
5 of 25 sample ratesHigher to lower in this preview
Inova Woodburn Surgery Center LLC
Inova Health Care Services
$8,078.00Published rateWest Hills Surgical Center Ltd
$3,792.00Published rateAmerican Access Care Of Jacksonville Asc LLC, Azura Surgery Center Jacksonville
American Access Care Of Jacksonville Asc LLC
$2,200.00Published rateThe Pottsville PA Endoscopy Asc Lp, Schuylkill Endoscopy Center
$1,520.00Published rateMcdowell Ambulatory Surgery Center LLC
$153.00Published rate
Get a free rate benchmark for your specialty.
Choose your state and specialty to build a report from payer-published rates.
Use market rates to prepare your payer proposal.
Payer Contract Negotiation
Draft a fee schedule renegotiation letter.
Use your fee schedule and market benchmarks to set target rates and draft a letter for your payer.
See a sample payer proposalCPT 42815 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42815 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 42815 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 |
|---|---|---|
| 42720-CPT | Moderate | Ncision & Drain Absces; Retropharyng Or Parapharyngeal Intr, Incision And Drainage Abscess; Retropharyngeal Or Parapharyngeal Intr |
| 42810-CPT | Moderate | Xcision Branchial Clft Cyst Or Vestig Confined To Skin & Subcuta, Excision Branchial Cleft Cyst Or Vestige Confined To Skin And Subcuta |
| 42815-CPT | Moderate | Excision Branchial Cleft Cyst, Excision Branchial Cleft Cyst Vestige Or Fistulaextending Beneath Subcutaneous Tissues Andor Into Pharynx |
| 42894-CPT | High | Revision Of Pharyngeal Walls, Resection Of Pharyngeal Wall Requiring Closure With Myocutaneous Or Fasciocutaneous Flap Or Free Muscle Skin Or Fascial Flap With Microvascular Anastomosis |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42815. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42815 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.
FREE SAMPLE MARKET COMPARISON
Let's review your payer contracts side-by-side with the market.
Bring your top codes (like CPT 42815) and we'll show you how you compare in 15 minutes or less.