How much does Medicare pay for CPT 43274?

Medicare allowed an average of $392.61 per service and paid $311.60 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $1824.95, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43274?

Insertion of stent into pancreatic or bile duct using a flexible endoscope. It was billed 29,282 times to 23,389 Medicare beneficiaries by 1,040 providers in 2024.

Does 43274 pay differently in an office than a hospital?

Yes. The allowed amount averaged $387.69 in an office setting and $392.61 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 43274 most?

Gastroenterology, with 27,610 services from 978 clinicians. Next are Internal Medicine, General Surgery, Surgical Oncology.

CPT 43274

Insertion of stent into pancreatic or bile duct using a flexible endoscope

$392.61Medicare-allowed amount per service, averaged across 29,282 services

Providers submitted

$1824.95

Asking price, not received

Medicare allowed

$392.61

The fee schedule figure

Medicare paid

$311.60

Balance is patient coinsurance

Providers submitted an average of $1824.95 for this code and Medicare allowed $392.61 — 4.6× 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 $311.60 (79%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $387.69
Hospital / facility: $392.61

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 15 services were billed in an office setting and 29,267 in a facility.

Services: 29,282
Beneficiaries: 23,389
Providers billing it: 1,040
Total allowed: $11,496,406

What Medicare pays for CPT 43274

Across 29,282 services billed by 1,040 providers to 23,389 beneficiaries, Medicare allowed an average of $392.61 per service. That is 1.3 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 43274

Specialty	Services	Beneficiaries	Avg allowed	Providers
Gastroenterology	27,610	22,044	$393.08	978
Internal Medicine	1,123	908	$393.03	44
General Surgery	328	255	$359.45	11
Surgical Oncology	114	89	$349.16	2
Hospitalist	63	57	$420.00	3
Pediatric Medicine	25	21	$399.45	1
Infectious Disease	19	15	$407.42	1

43274 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	2,734	$409.41	$285.61	90
Pennsylvania	1,541	$393.07	$292.77	59
Florida	1,532	$405.80	$304.11	61
Missouri	1,530	$366.56	$274.47	34
Texas	1,526	$394.33	$300.30	67
New York	1,436	$443.08	$296.88	62
Massachusetts	1,436	$398.89	$282.23	41
Illinois	1,348	$425.90	$306.43	52
Ohio	1,056	$390.78	$307.09	45
Virginia	1,019	$364.79	$270.54	32
Arizona	995	$348.97	$266.20	21
Washington	975	$394.16	$281.43	32
North Carolina	879	$369.62	$293.88	30
Michigan	878	$371.97	$274.48	35
Indiana	826	$372.08	$299.14	29
Minnesota	819	$350.22	$262.55	27
New Jersey	787	$422.56	$297.28	29
Maryland	716	$437.58	$309.60	26
South Carolina	666	$387.49	$310.59	19
Kentucky	592	$339.78	$251.23	14
Colorado	478	$377.94	$277.55	14
Wisconsin	463	$390.60	$322.93	27
Tennessee	435	$399.57	$331.68	21
Louisiana	387	$382.68	$303.69	13
Connecticut	338	$416.92	$294.43	15
Georgia	334	$398.98	$306.74	19
Oklahoma	298	$368.48	$291.11	7
Nebraska	296	$356.15	$295.41	8
West Virginia	283	$415.17	$319.07	10
Iowa	282	$336.30	$269.68	7
North Dakota	241	$347.70	$266.24	6
District of Columbia	213	$468.02	$315.21	5
Alabama	198	$376.16	$303.81	10
Kansas	196	$393.57	$316.06	6
Arkansas	181	$381.43	$312.38	6
New Hampshire	162	$409.05	$319.19	7
Nevada	144	$450.19	$345.55	5
Mississippi	136	$382.86	$312.67	7
Oregon	130	$369.17	$276.82	6
Delaware	123	$419.99	$333.34	6
South Dakota	114	$350.62	$278.52	4
Maine	112	$380.44	$290.03	4
Utah	99	$402.60	$313.99	5
Montana	96	$408.45	$303.07	5
Idaho	47	$387.91	$322.83	1
Hawaii	37	$369.55	$290.20	2
New Mexico	35	$447.56	$340.18	2
Guam	34	$409.42	$311.37	1
Vermont	33	$400.26	$315.96	2
Alaska	30	$497.01	$344.75	2
ZZ	22	$356.03	$311.95	1
Rhode Island	14	$424.83	$361.01	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
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.