CPT 43242 Fee Schedule

Medicare rates as of October 2026

CPT 43242 is classified under Surgery, in the Surgical Procedures on the Digestive System subgroup.

Endoscopic Procedure, Upper Gastrointestinal Endoscopy Including Esophagus Stomach And Either The Duodenum And/Or Jejunum As Appropriate; With Transendoscopic Ultrasound-Guided Intramural Or Transmural Fine Needle Aspiration/Biopsy(S)(Includes Endoscopic Ultrasound Examination Of The Esophagus Stomach And Either The Duodenum And/Or Jejunum As Appropriate)

Key Fact	Detail
Service Type	Surgery Surgical Procedures on the Digestive System
Common Place of Service	22 - On Campus Outpatient Hospital 21 - Inpatient Hospital
Common Modifiers	51 - Multiple procedures 59 - Distinct Procedural Service
Complexity Level	Moderate
Medicare Fee Schedule	$229.80 national non-facility rate (2026) · View Medicare rates for 43242
Medicaid Fee Schedule	$191.82 median of the 8 states in the free preview · View Medicaid rates for 43242

National average reimbursement for CPT 43242 by major payers:

$377.44

BCBS / Anthem

$421.86

UnitedHealthcare

$444.54

Aetna

$477.80

Cigna

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CPT 43242

5 of 25 sample ratesHigher to lower in this preview

Tuscan Surgery Center At Las Colinas, LLC, Tuscan Surgery Center At Las Colinas
TXAmbulatory Surgical Clinic/CenterNPI 1013227248Tax ID 27-3578014
$2,172.00Published rate
Monocacy Surgery Center LLC
Monocacy Surgery Center
MDAmbulatory Surgical Clinic/CenterNPI 1821421256Tax ID 46-2861862
$1,258.00Published rate
Bsc 1 LLC
AZAmbulatory Surgical Clinic/CenterNPI 1114549805Tax ID 85-1036387
$947.00Published rate
Smart Pain Surgery Center At Germantown, LLC, Clearway Surgery Center Of Germantown
Smart Pain Surgery Center At Germantown LLC
MDAmbulatory Surgical Clinic/CenterNPI 1730570003Tax ID 47-2908671
$611.00Published rate
Andrea Infantino
Deaconess Hospital Inc
TNCertified Registered Nurse AnesthetistNPI 1508238916Tax ID 35-0593390
$218.47Published rate

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Summit Women's CareDenver, Colorado

September 2, 2026

Contracting Manager
UnitedHealthcare
Commercial PPO

Re: Request for fee schedule renegotiation

We request a formal review of our Commercial PPO fee schedule. The comparison below summarizes our current rate alongside published rates for comparable Denver-area practices.

Market evidence · CPT 59485

Current rate: $152.40
Market median: $147.00
Market position: 61st percentile

The comparison includes 1,284 published rates from 96 provider groups, scoped to OB/GYN providers in a professional, office-based setting.

We would welcome a discussion of our fee schedule and the supporting July 2026 market analysis. Please let us know a suitable time to review the comparison together.

Sincerely,
Summit Women's Care

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CPT 43242 vs. Other Surgical Procedures on the Digestive System Codes

The table lists codes related to 43242. Select one to see its fee schedule.

Code	Complexity	Description
43238-CPT	Moderate	Esophagogastroduodenoscopy Flexible Transoral; With Transendoscopic Ultrasound-Guided Intramural Or Transmural Fine Needle Aspiration/Biopsy(S) Esophagus (Includes Endoscopic Ultrasound Examination Limited To The Esophagus Stomach Or Duodenum And Adjacent Structures) (Revised 01/01/2014)
43240-CPT	Moderate	Esophagogastroduodenoscopy Flexible Transoral; With Transmural Drainage Of Pseudocyst (Includes Placement Of Transmural Drainage Catheter[S]/ Stent[S] When Performed And Endoscopic Ultrasound When Performed) (Revised 01/01/2014)
43241-CPT	Moderate	Upper Gastrointestinal Endosco, Upper Gastrointestinal Endoscopy Including Esophagusstomach And Either The Duodenum Andor Jejunumas Appropriate With Transendoscopic Tube Or Cat Heter Placement
43242-CPT	Moderate	Endoscopic Procedure, Upper Gastrointestinal Endoscopy Including Esophagus Stomach And Either The Duodenum And/Or Jejunum As Appropriate; With Transendoscopic Ultrasound-Guided Intramural Or Transmural Fine Needle Aspiration/Biopsy(S)(Includes Endoscopic Ultrasound Examination Of The Esophagus Stomach And Either The Duodenum And/Or Jejunum As Appropriate)

What is a fee schedule?

A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43242. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.

Understanding the 43242 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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