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 |
| Medicare Fee Schedule | View Medicare rates for 43226 |
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 | $1000.00 | 1225439250 - ADVANCED SURGERY CENTER OF SAN ANTONIO, LLC | 465742281 - (TX) ADVANCED SURGERY CENTER OF SAN ANTONIO, LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $2114.00 | 1053585125 - BJOSC, LLC, BONE & JOINT SURGERY CENTER | 300391378 - BJOSC LLC | WI | 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 | $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 | $479.00 | 1770753998 - SKIN CANCER TREATMENT CENTER, L.L.C. | 262051034 - (MD) SKIN CANCER TREATMENT CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $947.00 | 1881225639 - BANNER SURGERY CENTER | 843441285 - (AZ) BANNER SURGERY CENTER | AZ | 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 | 43226 | $1174.00 | 1154805646 - ANNE ARUNDEL-SCA SURGICENTER, LLC, AAMC SURGERY CENTER - ANNAPOLIS | 824763728 - (MD) ANNE ARUNDELSCA SURGICENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $753.50 | 1477572675 - MOOTHEDATH A MENON, WIKA ENDOSCOPY CENTER | 363164643 - (CA) M.A. MENON, M.D. | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $536.00 | 1528039567 - PREMIER PROFESSIONAL SURGERY CENTER PC, PARKEYE SURGI CENTER | 381894684 - (MI) PARK EYE & SURGI CENTER | MI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $1233.00 | 1083938765 - MEDICAL PARK TOWER SURGERY CENTER, LLC, MEDICAL PARK TOWER SURGERY CENTER | 270543475 - (TX) MEDICAL PARK TOWER SURGERY CENTER LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $753.50 | 1528049855 - CENTER FOR AESTHETIC AND RECONSTRUCTIVE EYELID AND ORBITAL SURGERY, CAREOS | 844484446 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $554.00 | 1376650911 - ELM PLACE AMBULATORY SURGICAL CENTER | 752142438 - (TX) ELM PLACE AMBULATORY SURGICAL CENTER | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $1196.00 | 1609815075 - ORTHOATLANTA SURGERY CENTER OF FAYETTEVILLE, LLC | 202961633 - (GA) ORTHOATLANTA SURGERY CENTER OF FAYETTEVILLE LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43226 | $686.00 | 1962455964 - CYPRESS SURGERY CENTER LLC | 481214301 - (KS) CYPRESS SURGERY CENTER LLC | KS | 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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