Billing code 42281: Palate prosthesisMedicare rate & RVUs in Florida
Report palatal prosthesis insertion when a clinician places an obturator or similar device to address a palatal defect or oral-nasal communication.
Medicare pays $238.63–$262.17 for 42281 in the office in Florida, from Rest Of Florida to Miami. Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 42281 covers
This service covers placing a palatal prosthesis, such as an obturator, to help close a defect between the mouth and nasal cavity or support palatal function. It may be used for an acquired defect after surgery or trauma, or for a congenital palatal opening. An oral and maxillofacial surgeon, otolaryngologist, or other clinician involved in the patient’s palatal care may perform the insertion in a hospital or outpatient setting.
Report 42281 for insertion, not for palate reconstruction with the patient’s tissues. The record should identify the defect or functional problem, the prosthesis placed, and the insertion and fit assessment. CMS assigns a 10-day global period, so related postoperative visits during that period are included. When multiple procedures are performed in the same session, the highest-valued procedure is paid in full and other procedures are subject to the standard 50% reduction. Modifier 50 is not appropriate for this service. Assistant-at-surgery payment requires documentation of medical necessity; co-surgeons and team surgery are not permitted.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 42281 pays more and less in Florida
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
3 payment localities
$238.63 to $262.17
| Payment locality | Office | Facility |
|---|---|---|
| Fort Lauderdale | $250.96 | $161.97 |
| Miami | $262.17 | $170.72 |
| Rest Of Florida | $238.63 | $154.65 |
How the 42281 rate is calculated
Each of 42281’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 42281
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 1.93Practice expense 5.03Malpractice 0.27
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 42281
42281 has a 10-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42281
Palate prosthesis
| Rule | CMS value | What it means |
|---|---|---|
| Global period | 010 | Minor procedure: the day of the procedure plus 10 days after are included. |
| Multiple procedures | 2 | Standard reduction: highest-valued procedure at 100%, others at 50%. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 0 | Not paid without supporting documentation. |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
| Split (54/55/56) | 0.10/0.80/0.10 | Share of the payment for pre-op, the procedure itself, and post-op care. |
Global surgery period · 42281
Palate prosthesis
10-day global period ends
Oct 11, 2026
Covers Oct 1, 2026 through Oct 11, 2026 (11 days).
Visit on Oct 31, 2026
After the global period ends: visits and procedures are billed normally.
What modifiers do to the payment
Modifier 51 · payment effect
With and without the modifier
42281 without 51 · national office
$241.49
Palate prosthesis
42281-51 · Second procedure: 50%
$120.75
When this isn’t the highest-valued procedure in the session, Medicare pays 50% of its fee schedule amount (the highest is paid at 100%).
42281 compared with similar codes
Compare codes
42281 vs 42280 vs 42235 vs 42200: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 42280Palate mold
- Choose 42280 for preparation of a palate mold. Choose 42281 when the palatal prosthesis is inserted.
- 42235Palate repair
- 42235 describes surgical repair of the palate. 42281 describes placement of a prosthesis to address a defect.
- 42200Cleft palate repair
- 42200 is for cleft palate reconstruction; 42281 is for insertion of a palatal prosthesis rather than tissue reconstruction.
42281 billing questions
How is 42281 different from 42280?
42281 reports insertion of the palatal prosthesis. 42280 addresses preparation of a palate mold.
Is this code for surgical repair of a cleft palate?
No. 42281 describes prosthesis placement; cleft palate reconstruction codes describe operative repair using tissue.
What documentation supports 42281?
Document the palatal defect or functional problem, the prosthesis placed, and the insertion and fit assessment.
Are related postoperative visits separately payable?
Related postoperative visits within the 10-day global period are included in the procedure.
Can modifier 50 be appended?
No. The service is not reported as a bilateral procedure, so modifier 50 is inappropriate.
When may an assistant-at-surgery be reported?
Assistant-at-surgery payment is allowed only when the record documents medical necessity. Co-surgeons and team surgery are not permitted.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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