CPT code 42280: Palate mold2026 Medicare rate & RVUs in Virginia
Preparation of a custom palate mold for prosthetic management of a palatal defect, reported for mold preparation rather than prosthesis insertion.
Medicare pays $180.74–$211.08 for 42280 in the office in Virginia, from Virginia to Dc + Md/Va Suburbs. 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 42280 covers
This service prepares a custom mold shaped to the patient’s palate for prosthetic care of a palatal defect, such as one associated with a cleft. The mold is used in planning or making a palate prosthesis; this code describes preparation, not placement of the finished prosthesis. It is most relevant to care involving a prosthodontist or another clinician experienced in palatal prosthetics, often in an office setting.
Report the service when the record supports preparation of the patient-specific palate mold, rather than a palatal reconstruction or insertion of a prosthesis. Documentation should identify the defect being managed and the mold-preparation work performed. 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% multiple-procedure reduction. Modifier 50 is inappropriate. Assistant-at-surgery payment requires documented 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 42280 pays more and less in Virginia
| Payment locality | Office | Facility |
|---|---|---|
| Dc + Md/Va Suburbs | $211.08 | $108.78 |
| Virginia | $180.74 | $95.37 |
How the 42280 rate is calculated
Each of 42280’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 · 42280
RVUs × geographic indexes × conversion factor
Work1.55
1.55 RVUs× 1.000 GPCI
Practice expense3.77
3.77 RVUs× 1.000 GPCI
Malpractice0.22
0.22 RVUs× 1.000 GPCI
Adjusted RVUs
5.5400
Conversion factor
$33.4009
Medicare rate
$185.04
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 42280
42280 has a 10-day global period: related visits in that window are included in the surgery payment.
CMS payment indicators · 42280
Palate mold
| 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 · 42280
Palate mold
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
42280 without 51 · national office
$185.04
Palate mold
42280-51 · Second procedure: 50%
$92.52
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%).
42280 compared with similar codes
Compare codes · National
4 codes, side by side
How to choose
- 42281Palate prosthesis
- 42280 covers preparing the palate mold. Use 42281 for insertion of a palate prosthesis.
- 42200Cleft palate repair
- 42200 describes surgical cleft-palate reconstruction. 42280 is for mold preparation in prosthetic care, not operative repair.
- 42210Cleft palate repair
- 42210 is a palatal reconstruction procedure. Choose 42280 when the service is preparation of a custom palate mold rather than reconstruction.
42280 billing questions
When should this code be used instead of 42281?
Use 42280 for preparation of the custom palate mold. Code 42281 describes insertion of a palate prosthesis, not mold preparation.
Does this code describe a palate repair?
No. It represents mold preparation for prosthetic care; codes such as 42200 describe surgical reconstruction of the palate.
Are related postoperative visits separately reported?
Related postoperative visits during the 10-day global period are included in this service.
Can modifier 50 be appended?
No. CMS identifies bilateral adjustment as inappropriate for this code.
How are other procedures in the same session paid?
The highest-valued procedure is paid in full; other procedures in that session are subject to the standard multiple-procedure reduction.
Can an assistant or co-surgeon be reported?
Assistant-at-surgery payment requires documentation of 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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