Primary Removal Of Adenoids (12 Years Or Older)
Price Range Across States
What You Might Pay
Estimated using RAND 2024 commercial-to-Medicare ratios. Actual prices vary by insurer, plan, and facility.
How we estimate these prices
These estimates are based on the RAND Hospital Price Transparency Study (4th Edition, 2024), which found that commercial insurance prices average 224% of Medicare rates nationally. We apply category-specific ratios: Digestive Surgery procedures average 2.24x Medicare rates. Cash/self-pay estimates blend typical cash discounts (55% of billed charges) with Medicare-based estimates (150% of allowed amounts). These are statistical estimates, not quotes. Contact your insurer or provider for actual costs.
Prices by State
| State | Medicare Payment | Billed Charge |
|---|---|---|
| Florida | $295.32 | $2,803.32 |
| Pennsylvania | $252.06 | $1,747.42 |
What the Data Says About Primary Removal Of Adenoids (12 Years Or Older)
Across 2 states with reporting providers, CPT code 42831 (Primary Removal Of Adenoids (12 Years Or Older)) shows a national average Medicare payment of $268.27 against an average billed charge of $1,879.60. That gap — a 7.0x markup, or 601% above the Medicare allowed amount — reflects chargemaster pricing, not what most insured patients actually pay. Medicare's negotiated rate is the statutory benchmark; commercial insurers typically settle between the two figures based on network contracts.
Digestive Surgery procedures like this one saw 200 services billed to Medicare in 2023 by 187 distinct providers, serving 160 unique beneficiaries. State-level variation is significant: Pennsylvania reports the lowest average payment at $252.06, while Florida reports the highest at $295.32. Geographic Practice Cost Indices (GPCIs) explain much of that spread — local malpractice premiums, practice expense, and physician work adjustments all shift the allowed amount even when the procedure is identical.
Applying RAND 2024 commercial-to-Medicare ratios specific to the Digestive Surgery category (2.24x), the estimated commercial insurance price lands near $756.57, with self-pay cash discounts commonly bringing the figure closer to $770.21. Uninsured patients facing the full billed charge have the strongest leverage to negotiate — the Hospital Price Transparency Rule (effective January 2021) requires providers to publish standard charges, cash rates, and payer-specific negotiated prices. This data is for educational reference; confirm coverage and out-of-pocket exposure with your insurer before any procedure.
Frequently Asked Questions
How much does Primary Removal Of Adenoids (12 Years Or Older) cost?
The national average Medicare payment for Primary Removal Of Adenoids (12 Years Or Older) (CPT 42831) is $268.27, while providers typically bill $1,879.60. Prices vary significantly by state, ranging from $252.06 to $295.32.
Why do providers charge more than Medicare pays?
Providers set their own chargemaster rates (billed charges), which are typically much higher than what any insurer pays. Medicare pays a fixed rate based on the procedure code and geographic location. The billed charge is relevant mainly for uninsured patients, who may face prices closer to the submitted charge.
How much does Primary Removal Of Adenoids (12 Years Or Older) cost with insurance?
With commercial insurance, Primary Removal Of Adenoids (12 Years Or Older) costs an estimated $756.57 on average (range: $529.60 – $1,059.20). Without insurance, the estimated cash price is $770.21. These estimates are based on RAND 2024 research on commercial-to-Medicare price ratios. Your actual cost depends on your insurer, plan, and provider.
Which state has the lowest cost for Primary Removal Of Adenoids (12 Years Or Older)?
Pennsylvania has the lowest average Medicare payment for Primary Removal Of Adenoids (12 Years Or Older) at $252.06, while Florida has the highest at $295.32. This $43.26 difference reflects geographic variation in healthcare costs, local cost of living, and provider market dynamics.
How many providers perform Primary Removal Of Adenoids (12 Years Or Older)?
Nationally, 187 providers billed Medicare for Primary Removal Of Adenoids (12 Years Or Older) in 2023, performing 200 total services for 160 beneficiaries across 2 states and territories.
What is the billed-to-Medicare markup for Primary Removal Of Adenoids (12 Years Or Older)?
Providers bill 7.0x what Medicare pays for Primary Removal Of Adenoids (12 Years Or Older) — a 601% markup. This gap between billed charges and actual payment is common across healthcare. Uninsured patients may face charges closer to the billed amount, while insured patients pay negotiated rates between the Medicare and billed figures.
Related Guides
Tips to reduce out-of-pocket costs
Your right to upfront pricing
How Medicare payments work
Decode charges and codes
Why bills exceed actual costs
Geographic pricing factors
Related Data Sources
Data from CMS Medicare Physician & Other Practitioners (2023).
Read our methodology — how this data is sourced, computed, and verified.