How much does Medicare pay for CPT 43250?

Medicare allowed an average of $398.80 per service and paid $316.77 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $3817.20, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

Does 43250 pay differently in an office than a hospital?

Yes. The allowed amount averaged $195.07 in an office setting and $402.79 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 43250 most?

Ambulatory Surgical Center, with 1,035 services from 20 clinicians. Next are Gastroenterology, General Surgery, Colorectal Surgery (Proctology).

CPT 43250

Removal of polyps or growths of esophagus, stomach, and/or upper small bowel using a flexible endoscope with electrical cautery

$398.80Medicare-allowed amount per service, averaged across 2,397 services

Providers submitted

$3817.20

Asking price, not received

Medicare allowed

$398.80

The fee schedule figure

Medicare paid

$316.77

Balance is patient coinsurance

Providers submitted an average of $3817.20 for this code and Medicare allowed $398.80 — 9.6× 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 $316.77 (79%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $195.07
Hospital / facility: $402.79

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 46 services were billed in an office setting and 2,351 in a facility.

Services: 2,397
Beneficiaries: 2,268
Providers billing it: 51
Total allowed: $955,924

What Medicare pays for CPT 43250

Across 2,397 services billed by 51 providers to 2,268 beneficiaries, Medicare allowed an average of $398.80 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 43250

Specialty	Services	Beneficiaries	Avg allowed	Providers
Ambulatory Surgical Center	1,035	975	$755.22	20
Gastroenterology	1,013	950	$129.05	19
General Surgery	286	280	$120.33	9
Colorectal Surgery (Proctology)	41	41	$140.76	2
Internal Medicine	22	22	$152.97	1

43250 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	671	$392.92	$328.24	9
California	599	$534.95	$366.24	14
Illinois	412	$279.12	$227.22	7
Hawaii	173	$516.66	$361.14	2
Ohio	133	$228.65	$186.60	5
Maryland	132	$348.81	$291.86	2
New York	90	$225.85	$121.94	4
Texas	89	$458.13	$389.89	2
South Carolina	27	$443.72	$381.70	2
North Carolina	24	$102.10	$88.25	1
Michigan	22	$152.97	$120.17	1
Arkansas	14	$102.52	$75.60	1
New Jersey	11	$971.05	$652.10	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.