How much does Medicare pay for CPT 43235?

Medicare allowed an average of $145.31 per service and paid $112.98 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $965.73, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43235?

Diagnostic exam of esophagus, stomach, and/or upper small bowel using a flexible endoscope. It was billed 206,051 times to 201,320 Medicare beneficiaries by 7,186 providers in 2024.

Does 43235 pay differently in an office than a hospital?

Yes. The allowed amount averaged $146.37 in an office setting and $145.30 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 43235 most?

Gastroenterology, with 151,693 services from 5,587 clinicians. Next are Ambulatory Surgical Center, General Surgery, Internal Medicine.

CPT 43235

Diagnostic exam of esophagus, stomach, and/or upper small bowel using a flexible endoscope

$145.31Medicare-allowed amount per service, averaged across 206,051 services

Providers submitted

$965.73

Asking price, not received

Medicare allowed

$145.31

The fee schedule figure

Medicare paid

$112.98

Balance is patient coinsurance

Providers submitted an average of $965.73 for this code and Medicare allowed $145.31 — 6.6× 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 $112.98 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $146.37
Hospital / facility: $145.30

The office rate is higher because the practice supplies the room, staff and equipment out of that payment. In a hospital the facility bills those separately, so the clinician's share is smaller — the total cost to Medicare is usually higher, not lower. 1,958 services were billed in an office setting and 204,093 in a facility.

Services: 206,051
Beneficiaries: 201,320
Providers billing it: 7,186
Total allowed: $29,941,271

What Medicare pays for CPT 43235

Across 206,051 services billed by 7,186 providers to 201,320 beneficiaries, Medicare allowed an average of $145.31 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 43235

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	151,693	148,116	$102.83	5,587
Ambulatory Surgical Center	36,304	35,660	$345.95	805
General Surgery	8,285	8,045	$91.81	395
Internal Medicine	8,282	8,077	$106.04	334
Thoracic Surgery	567	535	$87.49	29
Hospitalist	267	261	$110.33	10
Emergency Medicine	82	82	$91.35	3
Pediatric Medicine	59	56	$101.57	1
Osteopathic Manipulative Medicine	55	54	$79.26	1
Cardiac Surgery	53	49	$97.70	3
Colorectal Surgery (Proctology)	53	52	$79.79	4
Vascular Surgery	52	52	$92.59	2
Nurse Practitioner	47	43	$94.60	1
Physician Assistant	40	39	$94.98	1
Endocrinology	36	33	$111.04	1

43235 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
California	15,370	$169.81	$117.64	568
Florida	13,408	$152.49	$122.03	469
Texas	13,326	$144.69	$117.51	467
Pennsylvania	10,655	$153.81	$122.50	404
Ohio	9,953	$144.75	$118.01	385
Tennessee	8,114	$139.47	$118.74	197
North Carolina	7,593	$156.50	$127.91	269
Massachusetts	6,659	$128.98	$95.92	239
Indiana	6,608	$145.15	$118.48	204
Illinois	6,506	$127.52	$97.82	263
New York	6,490	$142.94	$104.18	291
Missouri	6,265	$123.77	$100.78	204
South Carolina	6,179	$144.80	$119.52	159
Michigan	6,144	$152.51	$122.11	223
Virginia	5,129	$116.81	$90.21	176
Arizona	5,050	$145.40	$114.97	166
Georgia	4,977	$140.75	$113.34	208
Maryland	4,583	$155.39	$119.07	152
Mississippi	4,066	$159.48	$140.41	86
Washington	3,963	$157.80	$117.13	169
Kansas	3,903	$139.41	$116.70	102
Alabama	3,785	$132.86	$115.53	115
Oklahoma	3,688	$126.22	$105.23	86
Louisiana	3,659	$141.00	$119.21	111
Kentucky	3,341	$120.45	$98.53	129
Colorado	3,147	$164.71	$128.79	121
Wisconsin	2,957	$118.27	$96.43	135
Arkansas	2,746	$144.03	$123.00	68
Nebraska	2,612	$140.01	$114.01	71
Minnesota	2,382	$150.06	$116.60	102
New Jersey	2,364	$142.48	$103.52	121
Oregon	2,332	$173.75	$128.03	82
Iowa	2,084	$140.94	$118.71	71
Utah	1,788	$144.62	$114.13	53
Nevada	1,405	$176.54	$137.27	53
New Hampshire	1,401	$126.11	$98.05	48
Connecticut	1,287	$152.20	$112.34	68
New Mexico	1,223	$185.06	$142.25	32
West Virginia	1,121	$107.45	$85.33	37
Delaware	1,110	$147.94	$114.94	33
Idaho	1,040	$148.80	$123.21	39
Montana	976	$115.53	$88.22	26
North Dakota	856	$107.85	$86.00	20
South Dakota	838	$116.84	$96.36	28
Maine	725	$125.37	$96.88	35
Vermont	521	$124.33	$99.66	17
Alaska	457	$227.41	$143.17	21
Rhode Island	415	$153.13	$120.89	18
Hawaii	333	$177.41	$131.13	18
District of Columbia	249	$113.20	$77.87	13
Wyoming	203	$186.77	$149.25	11
ZZ	38	$99.93	$87.46	2
Guam	27	$87.61	$68.36	1

Related codes

43239Biopsy of esophagus$167.49
43249Balloon dilation of esophagus$337.40
43248Insertion of guide wire$223.15
43264Removal of stone or debris from bile or pancreatic duct$135.60
43251Removal of polyps or growths of esophagus$419.64
43274Insertion of stent into pancreatic or bile duct$392.61
43259Ultrasound exam of esophagus$230.50
43242Ultrasound guided needle aspiration or biopsy of esophagus$249.98
43255Control of bleeding of esophagus$200.78
43237Ultrasound exam of esophagus$204.08
43246Insertion of stomach tube$194.27
43238Ultrasound guided needle aspiration or biopsy of esophagus$222.24

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.