How much does Medicare pay for CPT 43245?

Medicare allowed an average of $209.08 per service and paid $163.83 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1635.75, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43245?

Dilation of stomach outlet using a flexible endoscope. It was billed 2,339 times to 2,136 Medicare beneficiaries by 95 providers in 2024.

Does 43245 pay differently in an office than a hospital?

Yes. The allowed amount averaged $635.38 in an office setting and $206.51 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 43245 most?

Gastroenterology, with 1,476 services from 61 clinicians. Next are Ambulatory Surgical Center, General Surgery, Thoracic Surgery.

CPT 43245

Dilation of stomach outlet using a flexible endoscope

$209.08Medicare-allowed amount per service, averaged across 2,339 services

Providers submitted

$1635.75

Asking price, not received

Medicare allowed

$209.08

The fee schedule figure

Medicare paid

$163.83

Balance is patient coinsurance

Providers submitted an average of $1635.75 for this code and Medicare allowed $209.08 — 7.8× 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 $163.83 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $635.38
Hospital / facility: $206.51

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. 14 services were billed in an office setting and 2,325 in a facility.

Services: 2,339
Beneficiaries: 2,136
Providers billing it: 95
Total allowed: $489,038

What Medicare pays for CPT 43245

Across 2,339 services billed by 95 providers to 2,136 beneficiaries, Medicare allowed an average of $209.08 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 43245

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	1,476	1,356	$130.74	61
Ambulatory Surgical Center	364	350	$608.91	12
General Surgery	241	208	$154.02	9
Thoracic Surgery	101	86	$151.75	5
Internal Medicine	79	69	$129.39	5
Family Practice	44	39	$166.31	1
Cardiac Surgery	34	28	$130.41	2

43245 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
Nebraska	367	$146.94	$116.94	3
California	254	$346.24	$239.35	11
Mississippi	198	$186.72	$156.87	6
Michigan	153	$263.27	$204.12	7
Florida	126	$208.63	$162.64	8
Pennsylvania	115	$160.71	$124.60	4
Ohio	105	$228.08	$182.91	5
Washington	91	$146.51	$113.91	3
Idaho	87	$155.66	$112.10	3
Utah	83	$131.85	$104.68	3
Kentucky	79	$138.89	$104.02	2
Missouri	79	$237.72	$195.73	5
Illinois	76	$155.62	$110.36	3
Texas	50	$116.74	$92.22	3
Arizona	49	$120.97	$84.81	3
New York	44	$293.74	$197.71	2
Massachusetts	40	$162.39	$122.11	2
West Virginia	33	$130.51	$102.51	2
Indiana	26	$122.97	$98.66	2
Wyoming	26	$783.86	$622.59	1
Arkansas	24	$148.14	$115.08	2
New Jersey	23	$161.77	$102.24	2
Louisiana	21	$602.76	$571.55	1
North Dakota	20	$98.71	$78.11	1
North Carolina	20	$83.24	$61.16	1
Tennessee	20	$726.21	$633.11	1
Colorado	18	$154.55	$109.93	1
Oklahoma	18	$118.69	$94.76	1
Alabama	14	$122.76	$102.04	1
South Dakota	14	$133.35	$111.57	1
Maryland	14	$644.52	$652.08	1
Oregon	14	$151.99	$125.46	1
Kansas	13	$142.42	$97.52	1
Iowa	13	$84.80	$57.75	1
Connecticut	12	$168.99	$114.19	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
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

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.