How much does Medicare pay for CPT 43255?

Medicare allowed an average of $200.78 per service and paid $158.71 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1220.13, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43255?

Control of bleeding of esophagus, stomach, and/or upper small bowel using a flexible endoscope. It was billed 17,476 times to 16,197 Medicare beneficiaries by 919 providers in 2024.

Does 43255 pay differently in an office than a hospital?

Yes. The allowed amount averaged $509.01 in an office setting and $197.01 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 43255 most?

Gastroenterology, with 15,737 services from 828 clinicians. Next are Internal Medicine, Ambulatory Surgical Center, General Surgery.

CPT 43255

Control of bleeding of esophagus, stomach, and/or upper small bowel using a flexible endoscope

$200.78Medicare-allowed amount per service, averaged across 17,476 services

Providers submitted

$1220.13

Asking price, not received

Medicare allowed

$200.78

The fee schedule figure

Medicare paid

$158.71

Balance is patient coinsurance

Providers submitted an average of $1220.13 for this code and Medicare allowed $200.78 — 6.1× 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 $158.71 (79%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $509.01
Hospital / facility: $197.01

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. 211 services were billed in an office setting and 17,265 in a facility.

Services: 17,476
Beneficiaries: 16,197
Providers billing it: 919
Total allowed: $3,508,831

What Medicare pays for CPT 43255

Across 17,476 services billed by 919 providers to 16,197 beneficiaries, Medicare allowed an average of $200.78 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 43255

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	15,737	14,584	$184.65	828
Internal Medicine	1,066	993	$181.15	56
Ambulatory Surgical Center	458	413	$765.47	23
General Surgery	75	71	$180.70	5
Hospitalist	66	65	$183.09	4
Family Practice	53	51	$553.36	2
General Practice	21	20	$208.00	1

43255 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	2,068	$232.56	$165.67	103
Florida	1,828	$223.15	$170.25	82
Texas	1,431	$178.55	$140.52	70
New York	835	$203.07	$139.37	44
Illinois	666	$186.59	$140.05	37
Indiana	568	$168.65	$140.70	33
Michigan	535	$185.25	$141.60	29
South Carolina	534	$197.44	$157.84	29
Tennessee	521	$194.59	$161.93	35
Ohio	514	$213.86	$171.27	27
Virginia	513	$188.81	$144.38	27
New Jersey	496	$194.45	$140.47	30
Nebraska	487	$255.75	$208.77	9
Missouri	466	$174.70	$137.83	25
Washington	440	$175.87	$137.57	24
Maryland	396	$206.82	$154.95	21
Arizona	362	$178.07	$139.40	20
Pennsylvania	344	$197.06	$152.67	21
North Carolina	344	$195.33	$161.15	20
Oklahoma	322	$169.65	$139.83	17
Arkansas	291	$232.33	$199.32	16
Massachusetts	288	$195.02	$146.05	20
Kentucky	267	$173.77	$136.67	16
North Dakota	241	$176.02	$138.51	8
Alabama	233	$283.73	$251.37	13
Kansas	229	$172.80	$141.48	13
Nevada	221	$186.35	$142.07	11
West Virginia	221	$167.73	$136.30	10
Louisiana	209	$214.64	$177.03	14
Georgia	169	$177.54	$145.89	12
Mississippi	164	$174.35	$144.74	8
Iowa	160	$218.63	$182.33	10
Minnesota	160	$187.50	$139.06	9
Colorado	146	$185.99	$149.45	8
Delaware	128	$180.57	$139.65	5
Idaho	87	$177.29	$145.37	6
Wisconsin	86	$160.01	$132.27	6
Connecticut	78	$194.38	$141.62	4
Oregon	67	$188.80	$140.64	5
New Hampshire	61	$178.98	$142.50	3
Utah	51	$183.60	$152.07	3
Montana	48	$182.46	$144.55	3
Hawaii	41	$392.76	$278.83	3
District of Columbia	41	$175.06	$119.69	2
Rhode Island	38	$180.30	$141.12	3
Maine	22	$172.12	$130.98	1
Alaska	18	$210.81	$145.00	1
Vermont	15	$179.72	$148.50	1
New Mexico	13	$178.77	$131.16	1
South Dakota	13	$183.79	$147.08	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
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.