CPT 43204 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Digestive System |
| Common Place of Service | • 21 - Inpatient Hospital • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • AG - Primary physician |
| Complexity Level | Moderate |
| CMS | $130.03 Physician Fee Schedule |
National average reimbursement for CPT 43204 by major payers:
$221.97
$221.37
$208.83
$257.05
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
Select a payer to view fee schedule data Choose a payer from the options above to see rates for CPT 43204 | ||||||
United | 43204 | $580.00 | 1205853041 - EUCLID ENDOSCOPY CENTER, LP | 203197449 - (CA) EUCLID ENDOSCOPY CENTER LP | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $1276.00 | 1821036138 - GAMMA SURGERY CENTER LLC | 270128900 - (PA) GAMMA SURGERY CENTER LLC | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $1528.00 | 1104974310 - NORTHWEST SURGERY CENTER, LLP, NORTHWEST SURGERY CENTER | 205537270 - (TX) NORTHWEST SURGERY CENTER LLP | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $773.00 | 1619576824 - SURGICARE OF LA VETA, LTD., NEWPORT COAST SURGICAL INSTITUTE | 752507129 | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $1528.00 | 1295142511 - BAY AREA ENDOSCOPY CENTER LLC | 463916191 - (CA) BAY AREA ENDOSCOPY CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $753.50 | 1356878052 - PAVILION SURGERY CENTER LLC | 814376492 - (CA) PAVILION SURGERY CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $512.00 | 1407335458 - MERRITT ISLAND OUTPATIENT SURGERY CENTER, LLC | 821391712 - (FL) MERRITT ISLAND OUTPATIENT SURGERY CENTER LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $934.00 | 1669895512 - AMBULATORY SURGICAL CENTER OF SOMERVILLE LLC, SOMERSET AMBULATORY SURGICAL CENTER | 371743209 | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $1258.00 | 1932636123 - TUCSON DIGESTIVE INSTITUTE LLC, ARIZONA DIGESTIVE INSTITUTE | 821568426 | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $464.00 | 1073094660 - CENTRAL VALLEY SURGICAL CENTER LLC | 825115030 - (CA) CENTRAL VALLEY SURGICAL CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $364.00 | 1043367196 - SURGICAL SPECIALISTS GROUP, LLC, ALABAMA OUTPATIENT SURGERY CENTER | 201398879 - (AL) SURGICAL SPECIALISTS GROUP, LLC | AL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $1276.00 | 1568967131 - CENTRAL MAINE EYE SURGERY CENTER LLC | 824811437 - (ME) CENTRAL MAINE EYE SURGERY CENTER LLC | ME | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $784.00 | 1265851034 - HANCOCK PARK SURGERY CENTER, LLC | 465306378 - (CA) HANCOCK PARK SURGERY CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $464.00 | 1831109875 - M-S SURGERY CENTER LLC | 205219388 - (CA) MS SURGERY CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43204 | $800.00 | 1033154851 - PARKWEST SURGERY CENTER LP | 621808841 - (TN) PARKWEST SURGERY CENTER LP | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 43204 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43204 code is part of the Surgery services used for Surgical Procedures on the Digestive System. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 43204 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 43201-CPT | Moderate | Esophagoscopy Flexible Transoral; With Directed Submucosal Injection(S) Any Substance (Revised 01/01/2014) |
| 43202-CPT | Moderate | Esophagoscopy Flexible Transoral; With Biopsy Single Or Multiple (Revised 01/01/2014) |
| 43204-CPT | Moderate | Esophagoscopy Flexible Transoral; With Injectionsclerosis Of Esophageal Varices (Revised 01/01/2014) |
| 43205-CPT | Moderate | Esophagoscopy Flexible Transoral; With Band Ligation Of Esophageal Varices (Revised 01/01/2014) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43204. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43204 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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