How much does Medicare pay for CPT 43249?

Medicare allowed an average of $337.40 per service and paid $265.88 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1906.45, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43249?

Balloon dilation of esophagus, stomach, and/or upper small bowel using a flexible endoscope, less than 3.0 cm. It was billed 123,222 times to 112,877 Medicare beneficiaries by 3,704 providers in 2024.

Does 43249 pay differently in an office than a hospital?

Yes. The allowed amount averaged $727.35 in an office setting and $323.26 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 43249 most?

Gastroenterology, with 78,025 services from 2,602 clinicians. Next are Ambulatory Surgical Center, Internal Medicine, General Surgery.

CPT 43249

Balloon dilation of esophagus, stomach, and/or upper small bowel using a flexible endoscope, less than 3.0 cm

$337.40Medicare-allowed amount per service, averaged across 123,222 services

Providers submitted

$1906.45

Asking price, not received

Medicare allowed

$337.40

The fee schedule figure

Medicare paid

$265.88

Balance is patient coinsurance

Providers submitted an average of $1906.45 for this code and Medicare allowed $337.40 — 5.7× 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 $265.88 (79%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $727.35
Hospital / facility: $323.26

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. 4,311 services were billed in an office setting and 118,911 in a facility.

Services: 123,222
Beneficiaries: 112,877
Providers billing it: 3,704
Total allowed: $41,575,103

What Medicare pays for CPT 43249

Across 123,222 services billed by 3,704 providers to 112,877 beneficiaries, Medicare allowed an average of $337.40 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 43249

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	78,025	71,086	$152.57	2,602
Ambulatory Surgical Center	36,613	34,076	$776.96	772
Internal Medicine	4,225	3,861	$157.19	144
General Surgery	3,554	3,188	$128.47	150
Thoracic Surgery	203	147	$128.73	8
Hospitalist	138	127	$130.24	7
Family Practice	100	92	$123.72	6
Emergency Medicine	79	75	$132.38	3
Otolaryngology	76	41	$135.67	2
Vascular Surgery	49	46	$132.06	1
Osteopathic Manipulative Medicine	35	35	$119.17	2
Critical Care (Intensivists)	29	18	$143.20	1
Colorectal Surgery (Proctology)	22	20	$119.31	1
Pediatric Medicine	16	14	$132.52	1
Endocrinology	16	15	$137.82	1

43249 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
Florida	12,154	$392.97	$327.07	318
Texas	10,664	$387.99	$322.69	312
California	9,124	$424.89	$284.12	290
North Carolina	6,232	$359.45	$302.45	175
Ohio	5,101	$326.16	$270.84	163
Alabama	4,805	$296.40	$275.33	92
Georgia	4,190	$317.65	$260.46	131
Illinois	4,105	$352.13	$281.68	142
Missouri	3,777	$244.65	$202.16	109
Kentucky	3,436	$289.49	$244.01	92
Virginia	3,360	$355.93	$277.12	110
Oklahoma	3,107	$258.53	$220.62	66
Utah	3,020	$279.64	$228.16	63
Arkansas	2,930	$387.26	$337.45	57
Tennessee	2,787	$334.46	$285.65	76
Indiana	2,769	$240.92	$197.20	96
Arizona	2,711	$390.57	$316.60	80
South Carolina	2,698	$279.06	$235.47	82
Colorado	2,419	$340.09	$272.26	82
Wisconsin	2,253	$209.16	$170.28	89
Iowa	2,242	$316.44	$272.30	57
Pennsylvania	2,114	$295.13	$239.59	92
Massachusetts	2,039	$262.36	$196.76	93
Washington	2,007	$331.17	$246.91	70
New York	1,890	$412.82	$312.99	69
Kansas	1,880	$258.02	$219.38	56
Maryland	1,871	$381.75	$311.10	58
Michigan	1,771	$358.23	$294.98	76
Louisiana	1,741	$347.89	$307.21	46
Nebraska	1,305	$225.30	$186.91	23
New Hampshire	1,285	$206.26	$161.71	41
Mississippi	1,232	$339.20	$313.72	33
Nevada	1,072	$451.54	$352.90	35
Minnesota	1,058	$326.83	$254.93	36
Idaho	936	$216.52	$181.64	30
New Jersey	913	$491.25	$358.94	43
Montana	784	$185.69	$145.97	24
Oregon	725	$457.66	$336.93	29
Wyoming	613	$374.11	$310.00	16
Connecticut	598	$415.66	$308.60	27
New Mexico	571	$368.39	$297.23	15
Maine	522	$233.59	$181.99	23
Delaware	496	$382.69	$292.60	16
North Dakota	445	$140.74	$109.90	10
South Dakota	379	$119.77	$95.99	14
West Virginia	366	$118.57	$94.66	14
Rhode Island	348	$295.82	$230.53	14
Vermont	157	$293.79	$236.11	6
Hawaii	90	$440.74	$340.70	5
Alaska	73	$584.31	$345.34	5
District of Columbia	33	$145.91	$93.02	2
ZZ	24	$111.17	$96.60	1

Related codes

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