How much does Medicare pay for CPT 43259?

Medicare allowed an average of $230.50 per service and paid $179.15 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1118.48, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43259?

Ultrasound exam of esophagus, stomach, and/or upper small bowel using a flexible endoscope. It was billed 28,795 times to 27,992 Medicare beneficiaries by 843 providers in 2024.

Does 43259 pay differently in an office than a hospital?

Yes. The allowed amount averaged $210.89 in an office setting and $230.57 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 43259 most?

Gastroenterology, with 25,619 services from 759 clinicians. Next are Ambulatory Surgical Center, Internal Medicine, Pediatric Medicine.

CPT 43259

Ultrasound exam of esophagus, stomach, and/or upper small bowel using a flexible endoscope

$230.50Medicare-allowed amount per service, averaged across 28,795 services

Providers submitted

$1118.48

Asking price, not received

Medicare allowed

$230.50

The fee schedule figure

Medicare paid

$179.15

Balance is patient coinsurance

Providers submitted an average of $1118.48 for this code and Medicare allowed $230.50 — 4.9× 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 $179.15 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $210.89
Hospital / facility: $230.57

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 110 services were billed in an office setting and 28,685 in a facility.

Services: 28,795
Beneficiaries: 27,992
Providers billing it: 843
Total allowed: $6,637,248

What Medicare pays for CPT 43259

Across 28,795 services billed by 843 providers to 27,992 beneficiaries, Medicare allowed an average of $230.50 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 43259

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	25,619	24,865	$196.88	759
Ambulatory Surgical Center	1,652	1,640	$783.14	38
Internal Medicine	1,442	1,405	$196.30	42
Pediatric Medicine	46	46	$227.06	1
Infectious Disease	14	14	$184.23	1
Surgical Oncology	11	11	$141.41	1
Hospitalist	11	11	$167.84	1

43259 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	4,123	$202.11	$141.33	90
Florida	3,269	$284.50	$226.03	84
New York	1,821	$283.85	$195.02	57
Texas	1,782	$254.32	$204.05	57
North Carolina	1,244	$243.76	$201.70	29
Massachusetts	1,201	$202.23	$142.32	28
Illinois	1,077	$217.28	$159.16	29
Missouri	1,066	$186.72	$148.60	24
Pennsylvania	1,044	$191.92	$145.90	37
New Jersey	923	$296.47	$213.11	29
Ohio	805	$240.89	$192.63	31
Maryland	779	$211.16	$151.87	20
Michigan	742	$219.33	$170.47	26
South Carolina	664	$192.19	$151.86	21
Alabama	637	$238.06	$207.57	13
Minnesota	580	$217.93	$169.67	20
Virginia	516	$190.74	$141.98	16
Louisiana	490	$254.98	$214.95	15
Arizona	479	$239.57	$185.85	17
Washington	465	$190.31	$139.99	14
Indiana	461	$269.33	$218.18	17
Georgia	449	$203.58	$155.69	21
Tennessee	412	$228.61	$184.02	10
Connecticut	354	$210.90	$149.48	14
Colorado	312	$198.20	$151.80	12
Mississippi	274	$306.24	$264.42	6
West Virginia	245	$199.63	$154.11	6
Kentucky	230	$179.56	$140.41	10
Nebraska	228	$182.26	$147.19	7
Wisconsin	224	$176.08	$139.24	12
Oregon	222	$196.30	$149.62	15
New Hampshire	222	$203.52	$154.88	4
District of Columbia	200	$241.22	$159.84	4
Kansas	195	$196.77	$158.42	5
New Mexico	128	$199.79	$150.52	4
Oklahoma	128	$174.75	$137.40	5
Nevada	124	$189.10	$145.94	4
Iowa	105	$180.87	$141.94	6
Idaho	79	$177.70	$155.48	2
Arkansas	73	$135.75	$109.82	2
Montana	73	$202.36	$153.35	3
Rhode Island	56	$212.95	$158.29	2
Utah	48	$202.37	$148.47	3
Delaware	46	$201.25	$156.60	3
Wyoming	46	$439.96	$383.64	2
Hawaii	40	$463.48	$332.13	3
Guam	36	$128.87	$100.88	1
Alaska	36	$270.64	$164.53	1
South Dakota	31	$170.36	$140.48	1
Maine	11	$183.06	$140.94	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
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.