How much does Medicare pay for CPT 43264?

Medicare allowed an average of $135.60 per service and paid $107.10 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1691.83, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43264?

Removal of stone or debris from bile or pancreatic duct using a flexible endoscope. It was billed 42,117 times to 34,823 Medicare beneficiaries by 1,404 providers in 2024.

Does 43264 pay differently in an office than a hospital?

Yes. The allowed amount averaged $157.86 in an office setting and $135.59 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 43264 most?

Gastroenterology, with 39,608 services from 1,314 clinicians. Next are Internal Medicine, General Surgery, Hospitalist.

CPT 43264

Removal of stone or debris from bile or pancreatic duct using a flexible endoscope

$135.60Medicare-allowed amount per service, averaged across 42,117 services

Providers submitted

$1691.83

Asking price, not received

Medicare allowed

$135.60

The fee schedule figure

Medicare paid

$107.10

Balance is patient coinsurance

Providers submitted an average of $1691.83 for this code and Medicare allowed $135.60 — 12.5× 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 $107.10 (79%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $157.86
Hospital / facility: $135.59

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. 23 services were billed in an office setting and 42,094 in a facility.

Services: 42,117
Beneficiaries: 34,823
Providers billing it: 1,404
Total allowed: $5,711,065

What Medicare pays for CPT 43264

Across 42,117 services billed by 1,404 providers to 34,823 beneficiaries, Medicare allowed an average of $135.60 per service. That is 1.2 services per beneficiary, so this is a code patients typically receive more than once. 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 43264

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	39,608	32,746	$134.22	1,314
Internal Medicine	1,853	1,548	$142.00	66
General Surgery	384	303	$112.82	14
Hospitalist	97	82	$198.28	3
Surgical Oncology	79	65	$44.58	2
Ambulatory Surgical Center	36	31	$1580.16	2
Pediatric Medicine	30	23	$106.60	1
Infectious Disease	19	14	$124.36	1
Nurse Practitioner	11	11	$294.28	1

43264 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	4,125	$139.94	$92.01	130
Texas	2,751	$129.73	$90.91	105
Florida	2,223	$149.97	$106.64	84
Illinois	2,203	$140.69	$93.65	69
Pennsylvania	2,084	$141.81	$98.95	73
New York	2,034	$163.78	$102.49	77
Massachusetts	1,860	$155.54	$105.71	49
Missouri	1,835	$91.29	$60.06	42
Michigan	1,463	$116.34	$78.49	47
Virginia	1,460	$97.48	$63.11	43
Washington	1,441	$123.69	$81.65	42
Ohio	1,362	$146.18	$108.28	50
North Carolina	1,298	$117.88	$83.75	40
Arizona	1,231	$111.06	$75.17	31
New Jersey	1,163	$146.73	$94.52	37
Indiana	1,107	$132.18	$99.44	37
Minnesota	1,042	$131.15	$94.12	34
Colorado	946	$107.97	$71.39	23
South Carolina	809	$116.85	$81.59	27
Maryland	752	$147.28	$98.62	28
Tennessee	714	$159.28	$122.54	34
Kentucky	683	$86.76	$57.15	21
Wisconsin	679	$155.01	$118.47	32
Louisiana	503	$120.74	$84.04	16
Connecticut	447	$136.06	$87.98	18
Georgia	440	$131.02	$92.72	22
West Virginia	437	$114.45	$78.19	11
Oklahoma	369	$146.12	$111.16	11
Alabama	347	$122.80	$88.96	14
Nebraska	326	$155.57	$120.28	9
Arkansas	312	$159.70	$125.64	12
District of Columbia	310	$67.21	$32.70	5
Iowa	289	$158.40	$122.35	8
North Dakota	284	$88.21	$59.35	7
Kansas	282	$154.57	$116.86	9
Delaware	250	$204.10	$155.93	9
Oregon	244	$152.87	$108.96	14
New Hampshire	244	$179.02	$133.83	8
Utah	234	$181.70	$134.29	10
Idaho	202	$146.24	$112.61	10
Mississippi	179	$182.89	$137.55	8
Maine	165	$131.48	$93.46	6
South Dakota	163	$92.19	$64.18	5
Nevada	163	$204.75	$151.40	8
New Mexico	148	$182.38	$131.57	6
Montana	139	$195.02	$144.93	6
Alaska	104	$587.75	$333.08	5
Vermont	73	$271.63	$218.67	4
Rhode Island	72	$193.51	$143.39	3
Hawaii	59	$92.34	$60.20	3
Guam	55	$97.00	$60.66	1
ZZ	12	$80.28	$61.43	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
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
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.