CPT 42970 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 | • 23 - Emergency Room • 11 - Office |
| Common Modifiers | • None • 78 - Return to OR - related procedure • 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
| CMS | $403.68 Physician Fee Schedule |
National average reimbursement for CPT 42970 by major payers:
$531.29
$539.20
$561.73
$677.58
| 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 42970 | ||||||
United | 42970 | $129.00 | 1073620415 - NORTH BAY EYE ASSOCIATES A MEDICAL CORPORATION, NORTH BAY EYE ASSOCIATES ASC | 680368973 - (CA) NORTH BAY EYE ASSOCIATES | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $484.00 | 1578525283 - PRINCETON ENDOSCOPY CENTER LLC | 200445094 - (NJ) PRINCETON ENDOSCOPY CENTER LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $333.07 | 1578081345 - ALEXANDRIA CARIE-KROEGER | 350593390 - DEACONESS HOSPITAL INC | IN | Nurse Practitioner (363L00000X) |
United | 42970 | $172.50 | 1700967106 - EBSC, LLC, SURGICAL CARE CENTER OF MICHIGAN | 382840421 - (MI) EBSC LLC | MI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $464.60 | 1740442615 - CENTER FOR ADVANCED REPRODUCTIVE SERVICES, PC, AMBULATORY SURGICAL CENTER AT REPRODUCTIVE SERVICES | 61522659 - (CT) CENTER FOR ADVANCED REPRODUCTIVE SERVICES, P.C. | CT | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $207.00 | 1164771762 - MARYLAND SPECIALTY SURGERY CENTER, LLC | 454793230 - (MD) MARYLAND SPECIALTY SURGERY CENTER, LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $180.00 | 1538722699 - R & R SURGICAL CENTERS | 820815470 - (CA) RR SURGICAL INSTITUTE | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $150.00 | 1679804355 - LONESTAR AMBULATORY SURGICAL CENTER | 263806076 - (TX) LONESTAR AMBULATORY SURGICAL CENTER | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $277.00 | 1609887413 - CSS JV, LLC, CENTER FOR SPECIALTY SURGERY | 263638838 - (OR) CSS JV LLC | OR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $179.00 | 1740287168 - AFFILIATED PHYSICIANS & SURGEONS, LTD | 860495569 - (AZ) AFFILIATED PHYSICIANS SURGEONS LTD | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $748.00 | 1891750980 - AMBULATORY SURGICAL FACILITY OF S FLORIDA LLLP, MEMORIAL SAME DAY SURGERY CENTERS | 592753716 - (FL) AMBULATORY SURGICAL FACILITY OF | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $1344.00 | 1164513149 - ENDO-SURGI OF UNION ASC LLC | 223248249 - (NJ) ENDO-SURGI CENTER, P.A. | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $88.00 | 1609568922 - BETHESDA ENDOSCOPY CENTER, LLC | 521915901 - (MD) BETHESDA ENDOSCOPY CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $724.91 | 1902301716 - QUAN DO | 350593390 - DEACONESS HOSPITAL INC | VA | Hematology & Oncology Physician (207RH0003X) |
United | 42970 | $400.00 | 1952912552 - SURGERY CENTER OF NORTH CENTRAL OHIO LLC, THE SURGERY CENTER OF NORTH CENTRAL OHIO | 833986181 - (OH) THE SURGERY CENTER OF NORTH CENT | OH | 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 42970 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42970 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 42970 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 |
| 42960-CPT | Moderate | Control Hemorrhage Oropharynx Simp |
| 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 42970. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42970 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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