How much does Medicare pay for CPT 42975?

Medicare allowed an average of $202.99 per service and paid $158.15 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1368.60, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 42975?

Evaluation of sleep-disordered breathing by examination of upper airway using an endoscope. It was billed 7,565 times to 7,541 Medicare beneficiaries by 359 providers in 2024.

Does 42975 pay differently in an office than a hospital?

Yes. The allowed amount averaged $97.37 in an office setting and $205.39 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 42975 most?

Otolaryngology, with 5,705 services from 267 clinicians. Next are Ambulatory Surgical Center, Pulmonary Disease, Maxillofacial Surgery.

CPT 42975

Evaluation of sleep-disordered breathing by examination of upper airway using an endoscope

$202.99Medicare-allowed amount per service, averaged across 7,565 services

Providers submitted

$1368.60

Asking price, not received

Medicare allowed

$202.99

The fee schedule figure

Medicare paid

$158.15

Balance is patient coinsurance

Providers submitted an average of $1368.60 for this code and Medicare allowed $202.99 — 6.7× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $158.15 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $97.37
Hospital / facility: $205.39

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 168 services were billed in an office setting and 7,397 in a facility.

Services: 7,565
Beneficiaries: 7,541
Providers billing it: 359
Total allowed: $1,535,619

What Medicare pays for CPT 42975

Across 7,565 services billed by 359 providers to 7,541 beneficiaries, Medicare allowed an average of $202.99 per service. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 42975

Specialty	Services	Beneficiaries	Avg allowed	Providers
Otolaryngology	5,705	5,687	$83.06	267
Ambulatory Surgical Center	1,656	1,652	$630.26	82
Pulmonary Disease	98	98	$86.49	5
Maxillofacial Surgery	63	63	$93.79	2
Oral Surgery (Dentist only)	23	22	$91.99	2
Nurse Practitioner	20	19	$78.87	1

42975 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
Florida	735	$196.87	$159.62	29
Texas	546	$259.51	$216.61	30
Arizona	430	$389.99	$313.99	15
California	346	$205.34	$134.50	20
Georgia	302	$125.64	$119.00	14
Mississippi	292	$183.17	$171.43	7
Iowa	289	$234.24	$199.09	9
Pennsylvania	279	$149.14	$115.39	15
Indiana	278	$322.14	$264.69	12
Missouri	277	$137.94	$107.79	13
South Carolina	250	$128.83	$104.37	11
Tennessee	215	$159.08	$139.35	11
Alabama	206	$113.64	$125.73	7
Illinois	204	$208.18	$207.62	12
Kansas	194	$303.78	$252.52	9
Virginia	189	$175.61	$162.40	10
Colorado	184	$300.11	$238.12	9
Ohio	173	$210.01	$175.45	10
Kentucky	170	$195.99	$158.64	8
Massachusetts	164	$142.20	$106.63	8
Louisiana	156	$89.03	$85.42	6
North Carolina	153	$168.00	$141.37	10
Oklahoma	149	$82.86	$67.07	6
Utah	135	$273.50	$221.64	10
New York	135	$96.57	$68.09	8
New Jersey	112	$382.59	$281.07	7
Washington	100	$224.13	$178.91	7
Nebraska	93	$81.29	$68.62	4
South Dakota	92	$61.10	$51.48	5
Wisconsin	82	$326.94	$285.28	5
Delaware	80	$220.77	$171.48	3
Minnesota	74	$172.60	$145.31	3
West Virginia	74	$94.96	$74.78	2
Idaho	65	$60.17	$53.50	3
Arkansas	64	$80.76	$71.93	3
Maryland	54	$411.75	$319.39	3
North Dakota	44	$89.42	$73.68	2
Michigan	36	$94.69	$75.81	3
New Hampshire	34	$281.51	$216.10	2
Maine	26	$85.39	$63.04	2
Nevada	22	$76.56	$58.62	1
New Mexico	17	$79.46	$58.78	1
Connecticut	12	$98.24	$66.70	1
Wyoming	11	$727.14	$593.54	1
Oregon	11	$87.93	$72.50	1
District of Columbia	11	$106.50	$58.57	1

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.