How much does Medicare pay for CPT 43242?

Medicare allowed an average of $249.98 per service and paid $195.71 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1334.15, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43242?

Ultrasound guided needle aspiration or biopsy of esophagus, stomach, and/or upper small bowel using a flexible endoscope. It was billed 22,177 times to 21,369 Medicare beneficiaries by 757 providers in 2024.

Does 43242 pay differently in an office than a hospital?

Yes. The allowed amount averaged $270.76 in an office setting and $249.91 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 43242 most?

Gastroenterology, with 20,392 services from 694 clinicians. Next are Internal Medicine, Ambulatory Surgical Center, General Surgery.

CPT 43242

Ultrasound guided needle aspiration or biopsy of esophagus, stomach, and/or upper small bowel using a flexible endoscope

$249.98Medicare-allowed amount per service, averaged across 22,177 services

Providers submitted

$1334.15

Asking price, not received

Medicare allowed

$249.98

The fee schedule figure

Medicare paid

$195.71

Balance is patient coinsurance

Providers submitted an average of $1334.15 for this code and Medicare allowed $249.98 — 5.3× 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 $195.71 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $270.76
Hospital / facility: $249.91

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. 74 services were billed in an office setting and 22,103 in a facility.

Services: 22,177
Beneficiaries: 21,369
Providers billing it: 757
Total allowed: $5,543,806

What Medicare pays for CPT 43242

Across 22,177 services billed by 757 providers to 21,369 beneficiaries, Medicare allowed an average of $249.98 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 43242

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	20,392	19,651	$234.35	694
Internal Medicine	1,071	1,021	$232.07	35
Ambulatory Surgical Center	662	647	$762.40	25
General Surgery	22	20	$218.32	1
Hospitalist	18	18	$210.40	1
Pediatric Medicine	12	12	$259.87	1

43242 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	2,776	$247.82	$178.61	78
Florida	2,018	$293.65	$229.26	69
Texas	1,217	$266.16	$215.62	45
Massachusetts	1,082	$243.91	$176.00	29
Pennsylvania	1,053	$233.56	$179.39	36
New York	1,003	$272.12	$185.64	39
Illinois	889	$255.63	$190.87	28
North Carolina	841	$217.21	$176.69	27
Missouri	786	$219.65	$174.98	23
Maryland	701	$243.61	$177.47	17
Michigan	678	$247.33	$188.59	28
Ohio	640	$235.56	$187.88	30
South Carolina	629	$225.91	$183.86	20
Minnesota	566	$234.79	$188.06	23
Tennessee	509	$252.26	$208.42	13
New Jersey	480	$258.48	$183.06	20
Virginia	477	$233.85	$180.19	18
Indiana	461	$350.89	$284.35	12
Washington	421	$232.22	$171.30	15
Georgia	396	$231.35	$180.11	19
Louisiana	351	$281.74	$237.49	11
Arizona	336	$278.26	$218.94	15
Wisconsin	309	$212.26	$178.24	16
Alabama	286	$282.08	$245.26	12
Colorado	250	$236.49	$180.96	9
Kansas	242	$235.04	$190.68	5
Nevada	229	$224.62	$170.92	6
Nebraska	223	$212.14	$178.16	7
Kentucky	219	$260.45	$209.68	11
Iowa	202	$209.77	$173.41	5
Connecticut	192	$248.56	$182.35	7
District of Columbia	187	$277.28	$190.42	5
West Virginia	183	$227.62	$174.59	7
Arkansas	177	$205.53	$170.78	2
New Hampshire	170	$237.47	$185.04	5
Oregon	160	$230.31	$182.61	10
Oklahoma	139	$200.24	$160.06	5
Mississippi	115	$220.44	$182.48	4
Idaho	111	$206.97	$175.85	5
New Mexico	85	$227.14	$181.24	4
Montana	79	$236.71	$180.20	3
Delaware	74	$239.70	$188.85	3
Utah	48	$225.95	$180.03	2
South Dakota	42	$220.60	$185.38	1
Rhode Island	39	$247.13	$183.56	2
Alaska	34	$302.08	$190.77	1
Maine	31	$215.73	$179.92	2
Hawaii	16	$218.38	$181.82	1
Guam	14	$183.62	$141.38	1
North Dakota	11	$201.44	$142.18	1

Related codes

43239Biopsy of esophagus$167.49
43235Diagnostic exam of esophagus$145.31
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
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.