How much does Medicare pay for CPT 43261?

Medicare allowed an average of $34.96 per service and paid $27.64 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1271.99, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43261?

Biopsy of gallbladder, pancreatic, liver, and bile ducts using a flexible endoscope. It was billed 1,191 times to 1,036 Medicare beneficiaries by 63 providers in 2024.

Which specialty bills 43261 most?

Gastroenterology, with 1,077 services from 56 clinicians. Next are Internal Medicine, Surgical Oncology, Ambulatory Surgical Center.

CPT 43261

Biopsy of gallbladder, pancreatic, liver, and bile ducts using a flexible endoscope

$34.96Medicare-allowed amount per service, averaged across 1,191 services

Providers submitted

$1271.99

Asking price, not received

Medicare allowed

$34.96

The fee schedule figure

Medicare paid

$27.64

Balance is patient coinsurance

Providers submitted an average of $1271.99 for this code and Medicare allowed $34.96 — 36.4× 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 $27.64 (79%); the rest is the patient’s coinsurance and deductible.

Services: 1,191
Beneficiaries: 1,036
Providers billing it: 63
Total allowed: $41,637

What Medicare pays for CPT 43261

Across 1,191 services billed by 63 providers to 1,036 beneficiaries, Medicare allowed an average of $34.96 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 43261

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	1,077	934	$25.36	56
Internal Medicine	75	66	$31.98	5
Surgical Oncology	26	23	$14.48	1
Ambulatory Surgical Center	13	13	$889.03	1

43261 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	174	$32.65	$16.71	10
Missouri	99	$23.70	$15.55	5
Virginia	96	$19.67	$10.11	4
Florida	78	$166.38	$133.65	5
New York	63	$31.50	$16.24	4
Oklahoma	62	$20.03	$10.21	2
Colorado	58	$28.72	$17.02	1
Indiana	50	$15.60	$6.12	3
Washington	48	$15.02	$6.14	3
Illinois	43	$40.87	$23.84	2
Nebraska	41	$14.10	$6.12	1
South Carolina	38	$22.55	$12.94	2
Michigan	37	$51.55	$33.67	2
North Carolina	36	$14.75	$6.12	1
New Jersey	32	$28.43	$14.07	2
Alabama	31	$24.02	$14.31	2
Arizona	28	$15.38	$6.13	2
Kentucky	27	$27.00	$15.52	2
Texas	26	$15.02	$5.88	2
Iowa	22	$14.27	$6.39	1
Maine	22	$30.46	$17.67	1
Tennessee	19	$67.47	$49.59	1
Minnesota	13	$15.57	$6.12	1
Pennsylvania	13	$41.01	$25.65	1
Arkansas	12	$14.13	$6.12	1
Mississippi	12	$15.32	$6.11	1
Ohio	11	$15.07	$6.09	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.