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 |
| Medicare Fee Schedule | View Medicare rates for 42970 |
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 | $914.00 | 1720543481 - SURGICAL SUITES OF COASTAL VIRGINIA, LLC | 833205375 - (VA) SURGICAL SUITES OF COASTAL VIRGINIA LLC | VA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $172.50 | 1700967106 - EBSC, LLC, SURGICAL CARE CENTER OF MICHIGAN | 382840421 - (MI) EBSC LLC | MI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $281.00 | 1619065273 - SHENANDOAH TX ENDOSCOPY ASC LLC, WOODLANDS ENDOSCOPY CENTER | 205301383 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $95.00 | 1164734232 - MIDSOUTH INTERVENTIONAL PAIN INSTITUTE, LLC | 272910652 - MIDSOUTH INTERVENTIONAL PAIN INSTITUTE LLC | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $200.00 | 1528061918 - CATARACT SPECIALTY SURGICAL CENTER, LLC, CATARACT SPECIALTY SURGICAL CENTER | 200225369 - (MI) CATARACT SPECIALTY SURGICAL CENTER LLC | MI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $907.00 | 1558564344 - SURGERY CENTER OF ATLANTIS LLC | 260298828 - (FL) SURGERY CENTER OF ATLANTIS LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $4097.00 | 1568094399 - SURGERY CENTER OF SOUTHWEST OHIO, LLC, THE SURGERY CENTER OF SOUTHWEST OHIO | 831673860 - (OH) THE SURGERY CENTER OF SOUTHWEST | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $175.00 | 1518280684 - NORTHWEST SURGERY CENTER, INC. | 364663721 - (CA) NORTHWEST SURGERY CENTER INC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $125.00 | 1194960732 - ISURGERY, LLC | 300514883 - (SD) ISURGERY LLC | SD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $329.00 | 1104894369 - VALLEY OUTPATIENT SURGICAL CENTER INC | 860585124 - (AZ) VALLEY OUTPATIENT SURGICAL CENTER INC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $1029.00 | 1104883784 - FORT WORTH ENDOSCOPY CENTERS, LLC, FORT WORTH ENDOSCOPY CENTER | 770368346 - (TX) FORT WORTH ENDOSCOPY CENTERS LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $1081.00 | 1902134372 - METRO SPECIALTY SURGERY CENTER, LLC | 270426722 - (IN) METRO SPECIALTY SURGERY CENTER LLC | IN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $221.00 | 1144673526 - MURRIETA VALLEY SURGERY CENTER, INC.A PROFESSIONAL CORPORATION | 813020819 - (CA) MURRIETA VALLEY SURGERY CENTER INCA PROFESSIONAL CORPORATION | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $37.00 | 1285633818 - FOUR CORNERS AMBULATORY SURGICAL CENTER LLC | 522208568 - (MD) FOUR CORNERS AMBULATORY SURGICAL CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42970 | $531.00 | 1598996894 - SURGICAL ELITE OF AVONDALE, LLC | 270471437 - (AZ) SURGICAL ELITE OF AVONDALE LLC | AZ | 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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