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See a sample rate comparisonCPT 42826 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 Age 12 And Over
| 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 51 - Multiple procedures |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $231.47 national non-facility rate (2026) · View Medicare rates for 42826 |
| Medicaid Fee Schedule | $199.17 median of the 8 states in the free preview · View Medicaid rates for 42826 |
National average reimbursement for CPT 42826 by major payers:
$330.85
$340.05
$374.66
$420.65
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CPT 42826
5 of 25 sample ratesHigher to lower in this preview
Physicians Surgery Center Of Tempe, LLC, Physicians Surgery Center Of Tempe
Physicians Surgery Center Of Tempe LLC
$2,388.00Published rateEvergreen Eye Center, PLLC, Evergreen Eye Surgery Center
Evergreen Eye Center, Inc. P.S.
$1,387.00Published rateLos Robles Surgicenter, LLC, Los Robles Surgicenter
Los Robles Surgicenter LLC
$1,072.50Published rateSpecialty Surgical Center Of Encino Lp
Specialty Surgical Center Of Encino, Lp
$591.00Published rateBay Area Endoscopy Center Limited Partnership
$360.00Published rate
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See a sample payer proposalCPT 42826 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42826 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 42826 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 42826. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42826 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
Finding the exact cost of a medical procedure or service can be challenging due to varying factors like your insurance plan, location, and specific provider. For a detailed estimate based on your specific situation, including CPT codes and your location, you can use tools like Payerprice's fee schedule lookup tool. This allows you to search for pricing information for specific services.
To look up negotiated rates for medical services specific to your location, you can utilize Payerprice. Their fee schedule lookup tool is designed to help users search for pricing information using CPT codes and specific geographical areas, providing a clearer picture of rates in your vicinity.
Comparing prices across different providers often requires access to their fee schedules. To effectively compare costs, you can use platforms like Payerprice. Their fee schedule lookup tool allows you to search for specific CPT codes and locations, which can help you gather pricing data from various sources and make informed decisions about different providers.
A CPT (Current Procedural Terminology) code is a standardized five-digit code used by medical professionals to describe medical, surgical, and diagnostic services. These codes are essential for billing and understanding the specific services you receive. To use CPT codes to understand healthcare costs, you can input them into Payerprice's fee schedule lookup tool, along with your specific location, to find out the associated pricing information for those services.
Healthcare prices can vary significantly due to factors such as geographical location, the type of facility (hospital vs. outpatient clinic), insurance negotiation differences, and the specific provider. To get a more accurate estimate tailored to your situation, it's best to use tools that aggregate pricing data. Payerprice offers a fee schedule lookup tool where you can search with specific CPT codes and your location to find more precise pricing information and estimates.