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See a sample rate comparisonCPT 42820 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.
Tonsillectomy & Adnoidectomy; Under Age
| Key Fact | Detail |
|---|---|
| Service Type | Surgery Surgical Procedures on the Digestive System |
| Common Place of Service | 24 - Ambulatory Surgical Center 22 - On Campus Outpatient Hospital |
| Common Modifiers | SG - Scene to Hospital ESRD facility AG - Primary physician |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $260.86 national non-facility rate (2026) · View Medicare rates for 42820 |
| Medicaid Fee Schedule | $210.98 median of the 8 states in the free preview · View Medicaid rates for 42820 |
National average reimbursement for CPT 42820 by major payers:
$365.72
$389.65
$426.23
$478.46
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CPT 42820
5 of 25 sample ratesHigher to lower in this preview
Tri-City Regional Surgery Center LLC
Tri-City Regional Surgery Center
$5,550.00Published rateDavid Robinson
Virginia Mason Medical Center
$806.41Published rateDennis Gaskill
Yakima Urology At Memorial Tr
$657.75Published rateAnthony Caruso
Surgical Associates Northwest, PC
$444.54Published rateNorthwest Spokane Pediatrics, PLLC, Joseph B Mcmanus Md
Northwest Spokane Pediatrics PLLC
$363.44Published rate
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See a sample payer proposalCPT 42820 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42820 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 42820 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 42820. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42820 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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Frequently Asked Questions
To get an estimate for a medical procedure, you'll need the specific CPT (Current Procedural Terminology) code for the service and your geographic location. Many providers can give you an estimate, but for a more comprehensive search across different payers, you can use tools like Payerprice. Their fee schedule lookup tool allows you to search with a CPT code and specific location to find pricing information.
CPT (Current Procedural Terminology) codes are a standardized set of five-digit codes used by healthcare providers to describe medical, surgical, and diagnostic services. They are crucial for billing and reimbursement processes, ensuring that healthcare services are accurately recorded and priced. Understanding the CPT code for your procedure can help you research costs and verify your medical bills.
Medical bills can be complex. Key components usually include the date of service, the provider's name, a description of services rendered (often with CPT codes), the billed amount, any insurance adjustments, and the amount you owe. If you have questions about specific charges, especially CPT codes, you can contact your provider's billing department or your insurance company. For understanding typical costs associated with CPT codes, resources like Payerprice can be helpful.
Insurance coverage depends on your specific plan, its benefits, deductibles, co-pays, and whether the procedure is deemed medically necessary. The best way to determine coverage is to contact your insurance provider directly. Provide them with the CPT code for the procedure, and they can inform you about your benefits, any pre-authorization requirements, and your estimated out-of-pocket costs.
Fee schedules, which list the maximum amount an insurer will pay for a specific service, are often proprietary to insurance companies. However, you can access pricing information for medical services by using tools designed for this purpose. Payerprice offers a fee schedule lookup tool that allows users to search with CPT codes and specific locations, providing insights into service costs from various payers. This can help you understand potential costs and compare prices.