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See a sample rate comparisonCPT 42955 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.
Pharyngostomy-Fistulization Pharynx,Exte
| Key Fact | Detail |
|---|---|
| Service Type | Surgery Surgical Procedures on the Digestive System |
| Common Place of Service | 21 - Inpatient Hospital 22 - On Campus Outpatient Hospital |
| Common Modifiers | GC - Service performed by resident under supervision 58 - Staged or related procedure during postoperative period |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $696.74 national non-facility rate (2026) · View Medicare rates for 42955 |
| Medicaid Fee Schedule | $565.78 median of the 8 states in the free preview · View Medicaid rates for 42955 |
National average reimbursement for CPT 42955 by major payers:
$978.60
$1,000.86
$1,047.88
$1,233.15
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CPT 42955
5 of 25 sample ratesHigher to lower in this preview
Central Austin Ambulatory Surgery Center L.P., Dba Central Park Surgery Center
$2,782.00Published rateGab Endoscopy Center LLC
$1,528.00Published rateDry Creek Surgery Center, LLC
Dry Creek Surgery Center LLC
$957.00Published rateRaleigh Nc Endoscopy Asc LLC, Raleigh Endoscopy Center - Cary
Raleigh Nc Endoscopy Asc LLC
$654.00Published rateGreen Surgery Center LLC
$393.00Published rate
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See a sample payer proposalCPT 42955 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42955 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 42955 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 |
|---|---|---|
| 42950-CPT | Moderate | Pharyngoplasty |
| 42953-CPT | High | Repair Pharyngoesophageal |
| 42955-CPT | Moderate | Pharyngostomy-Fistulization Pharynx,Exte |
| 42960-CPT | Moderate | Control Oropharyngeal Hemorrha, Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg Posttonsillectomy) Simple Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42955. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42955 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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