How much does Medicare pay for CPT 43281?

Medicare allowed an average of $1180.21 per service and paid $939.51 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $5230.43, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 43281?

Repair of hernia of muscle at esophagus and stomach using an endoscope. It was billed 4,776 times to 4,742 Medicare beneficiaries by 276 providers in 2024.

Which specialty bills 43281 most?

General Surgery, with 2,958 services from 172 clinicians. Next are Thoracic Surgery, Physician Assistant, Nurse Practitioner.

CPT 43281

Repair of hernia of muscle at esophagus and stomach using an endoscope

$1180.21Medicare-allowed amount per service, averaged across 4,776 services

Providers submitted

$5230.43

Asking price, not received

Medicare allowed

$1180.21

The fee schedule figure

Medicare paid

$939.51

Balance is patient coinsurance

Providers submitted an average of $5230.43 for this code and Medicare allowed $1180.21 — 4.4× 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 $939.51 (80%); the rest is the patient’s coinsurance and deductible.

Services: 4,776
Beneficiaries: 4,742
Providers billing it: 276
Total allowed: $5,636,683

What Medicare pays for CPT 43281

Across 4,776 services billed by 276 providers to 4,742 beneficiaries, Medicare allowed an average of $1180.21 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 43281

Specialty	Services	Beneficiaries	Avg allowed	Providers
General Surgery	2,958	2,937	$1292.14	172
Thoracic Surgery	907	899	$1516.59	49
Physician Assistant	569	568	$205.29	36
Nurse Practitioner	122	122	$194.82	8
Cardiac Surgery	81	80	$1550.88	4
General Practice	43	41	$1356.78	2
Gastroenterology	43	43	$890.83	2
Surgical Oncology	31	31	$1367.68	2
Cardiology	22	21	$1533.13	1

43281 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	663	$1118.12	$833.48	34
Florida	499	$1134.18	$792.15	27
Texas	456	$1250.34	$984.90	29
Missouri	247	$1154.94	$921.84	11
Illinois	223	$1199.69	$866.63	14
Virginia	171	$1036.12	$835.19	8
Pennsylvania	163	$1437.07	$1149.35	11
Massachusetts	156	$1392.33	$1043.93	7
Washington	154	$1198.35	$908.08	10
Tennessee	151	$1341.05	$1154.38	9
Georgia	137	$1102.30	$813.14	9
New York	124	$1623.05	$1073.34	8
Arizona	119	$722.76	$559.86	5
South Dakota	106	$796.93	$667.73	6
Maryland	103	$1233.81	$953.41	5
South Carolina	97	$1340.32	$1127.30	6
Indiana	97	$985.33	$806.49	6
Minnesota	83	$1149.12	$957.22	4
Ohio	73	$1399.77	$1148.09	4
Oregon	73	$713.69	$567.83	5
Iowa	70	$978.95	$853.57	4
Kentucky	66	$997.85	$856.15	4
Wisconsin	66	$1293.95	$1161.55	4
Louisiana	60	$1160.75	$941.18	4
Nebraska	59	$850.35	$743.47	5
Idaho	57	$905.13	$770.22	3
Utah	54	$1102.81	$912.10	4
North Carolina	54	$1411.66	$1168.62	4
Kansas	39	$1291.28	$1119.01	3
New Jersey	38	$1621.89	$1195.82	2
Connecticut	37	$1572.18	$1161.13	2
Michigan	36	$1279.97	$911.38	3
New Hampshire	31	$1046.10	$790.36	2
Delaware	29	$1554.30	$1196.21	2
Alabama	28	$1359.16	$1196.81	2
West Virginia	27	$1548.21	$1155.74	1
Arkansas	27	$1293.55	$1149.57	1
Mississippi	27	$819.44	$630.42	2
Colorado	26	$1397.90	$1115.21	2
District of Columbia	15	$1774.14	$1182.45	1
Oklahoma	12	$1481.52	$1180.47	1
Montana	12	$1279.22	$1247.24	1
Nevada	11	$1088.70	$994.99	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.