CPT 43226 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 | • 24 - Ambulatory Surgical Center • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • 51 - Multiple procedures • 59 - Distinct Procedural Service |
| Complexity Level | Moderate |
| CMS | $367.78 Physician Fee Schedule |
National average reimbursement for CPT 43226 by major payers:
$364.08
$383.79
$472.01
$559.65
| 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 43226 | ||||||
United | 43226 | $615.00 | 1316290380 - ATHENS SURGERY CENTER LLC, THE SURGERY CENTER OF ATHENS | 800812776 | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $2483.00 | 1114435856 - EINSTEIN MEDICAL CENTER MONTGOMERY, EINSTEIN ENDOSCOPY CENTER - BLUE BELL | 204193243 - (PA) ALBERT EINSTEIN HEALTHCARE NETWORK | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $1026.00 | 1811003205 - VIEWMONT SURGERY CENTER, LLC | 201133583 - (NC) VIEWMONT SURGERY CENTER LLC | NC | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $1558.00 | 1336437482 - HEALTHONE RIDGE VIEW ENDOSCOPY CENTER, LLC, RIDGE VIEW ENDOSCOPY CENTER | 800688043 | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $850.00 | 1962668319 - BOULDER MEDICAL CENTER, PC, BOULDER MEDICAL CENTER ASC | 840834835 - BOULDER MEDICAL CENTER, P.C. | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $753.50 | 1073944039 - THE POLYCLINIC, THE POLYCLINIC PLASTIC SURGERY CENTER | 910369070 - (WA) THE POLYCLINIC, PLLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $2251.00 | 1528104080 - SURGICAL CENTER AT CEDAR KNOLLS LLC | 202158771 - (NJ) SURGICAL CENTER AT CEDAR KNOLLS | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $670.00 | 1952834277 - AMERICAN ACCESS CARE OF TOWSON ASC LLC | 814571016 - (MD) AMERICAN ACCESS CARE OF TOWSON ASC LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $437.00 | 1942242441 - ADVANCED EYE SURGERY CENTER, LLC | 510567447 - (FL) ADVANCED EYE SURGERY CENTER LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $2761.00 | 1154454460 - TEXAS HEALTH HARRIS METHODIST HOSPITAL HURST-EULESS-BEDFORD | 751438726 - (TX) TEXAS HEALTH HARRIS METHODIST HOSPITAL HURST-EULESS-BEDFORD | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $1179.00 | 1093086183 - CHANDLER ENDOSCOPY AMBULATORY SURGERY CENTER, LLC, CHANDLER ENDOSCOPY CENTER | 454307241 | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $1039.00 | 1053366930 - ADVANCED SURGERY CENTER, LLC | 342045695 - (NE) ADVANCED SURGERY CENTER, LLC | NE | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $2889.00 | 1992058325 - SOUTH BEND SPECIALTY SURGERY CENTER, LLC | 460571418 - (IN) SOUTH BEND SPECIALTY SURGERY CENTER LLC | IN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $1258.00 | 1215091087 - CORPUS CHRISTI SURGICARE LTD, CHRISTUS SPOHN TEXAS ORTHOPEDIC CENTER OF EXCELLENCE | 753049514 - (TX) CORPUS CHRISTI SURGICARE LTD | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $1248.00 | 1063427706 - PROHEALTH AMBULATORY SURGERY CENTER INC | 113447394 - (NY) PROHEALTH AMBULATORY SURGERY CENTER INC | NY | 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 43226 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43226 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 43226 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 |
|---|---|---|
| 43220-CPT | Moderate | Esophagoscopy Flexible Transoral; With Transendoscopic Balloon Dilation (Less Than 30 Mm Diameter) (Revised 01/01/2014) |
| 43226-CPT | Moderate | Esophagoscopy Flexible Transoral; With Insertionof Guide Wire Followed By Passage Of Dilator(S) Over Guide Wire (Revised 01/01/2014) |
| 43229-CPT | Moderate | Esophagoscopy, Flexible, Transoral; With Ablation Of Tumor(S), Polyp(S), Or Other Lesion(S) (Includes Pre- And Post-Dilation And Guide Wire Passage, When Performed) |
| 43231-CPT | Moderate | Esophagoscopy Flexible Transoral; With Endoscopic Ultrasound Examination (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 43226. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43226 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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