How much does Medicare pay for CPT 43262?

Medicare allowed an average of $69.32 per service and paid $54.84 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1499.68, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43262?

Incision of pancreatic outlet using a flexible endoscope. It was billed 10,605 times to 10,416 Medicare beneficiaries by 581 providers in 2024.

Does 43262 pay differently in an office than a hospital?

Yes. The allowed amount averaged $34.96 in an office setting and $69.37 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 43262 most?

Gastroenterology, with 9,976 services from 548 clinicians. Next are Internal Medicine, General Surgery, Hospitalist.

CPT 43262

Incision of pancreatic outlet using a flexible endoscope

$69.32Medicare-allowed amount per service, averaged across 10,605 services

Providers submitted

$1499.68

Asking price, not received

Medicare allowed

$69.32

The fee schedule figure

Medicare paid

$54.84

Balance is patient coinsurance

Providers submitted an average of $1499.68 for this code and Medicare allowed $69.32 — 21.6× 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 $54.84 (79%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $34.96
Hospital / facility: $69.37

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 16 services were billed in an office setting and 10,589 in a facility.

Services: 10,605
Beneficiaries: 10,416
Providers billing it: 581
Total allowed: $735,139

What Medicare pays for CPT 43262

Across 10,605 services billed by 581 providers to 10,416 beneficiaries, Medicare allowed an average of $69.32 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 43262

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	9,976	9,798	$69.49	548
Internal Medicine	485	476	$62.12	24
General Surgery	94	92	$89.55	6
Hospitalist	38	38	$65.07	2
Nurse Practitioner	12	12	$71.38	1

43262 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	1,462	$71.71	$42.02	73
Texas	638	$58.48	$35.68	36
Florida	631	$76.28	$48.04	35
Pennsylvania	567	$69.51	$42.27	36
Massachusetts	529	$68.04	$39.11	27
Illinois	485	$59.87	$33.06	25
New York	448	$71.52	$37.64	24
Ohio	424	$65.33	$41.70	24
Washington	379	$56.41	$31.44	20
Tennessee	335	$85.56	$60.43	21
Indiana	279	$83.23	$57.25	16
North Carolina	278	$51.39	$31.43	16
Minnesota	257	$66.81	$42.76	15
New Jersey	249	$88.05	$50.96	12
Missouri	247	$71.87	$47.83	11
Maryland	224	$80.01	$49.55	12
Michigan	218	$55.74	$31.03	14
Virginia	206	$69.52	$42.57	11
Nevada	201	$105.32	$69.00	7
Wisconsin	191	$65.81	$43.39	13
Arizona	178	$58.79	$33.78	10
Colorado	164	$58.31	$34.38	11
Delaware	144	$60.80	$36.58	7
Nebraska	143	$74.18	$50.35	7
Georgia	130	$103.82	$73.00	9
South Carolina	128	$79.99	$57.71	8
Iowa	115	$62.10	$40.87	5
Oklahoma	111	$68.34	$45.23	5
West Virginia	101	$43.40	$23.22	6
Arkansas	97	$59.83	$39.82	6
Alabama	96	$48.83	$29.23	5
New Hampshire	96	$64.61	$40.27	5
Oregon	95	$107.83	$77.31	6
Kansas	85	$87.38	$60.48	5
Connecticut	83	$86.23	$50.07	5
Mississippi	82	$87.72	$60.89	4
Louisiana	67	$55.73	$26.67	4
Montana	63	$42.48	$20.68	4
Vermont	61	$42.98	$26.89	4
Maine	50	$59.68	$33.88	2
Utah	49	$50.41	$28.89	3
Kentucky	42	$51.29	$28.58	2
New Mexico	41	$34.20	$13.32	2
Rhode Island	41	$67.20	$40.04	2
North Dakota	26	$77.78	$52.82	2
Idaho	23	$81.20	$58.16	1
Alaska	20	$66.60	$38.86	1
South Dakota	14	$52.39	$31.69	1
Hawaii	12	$33.17	$13.00	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.