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See a sample rate comparisonCPT 43254 Fee Schedule
Last Verified: October 2026
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.
Scope Exam Of Stomach, Exam Of The Esophagus Stomach And Intestines Using A Scope (Endoscope). The Procedure Includes Removing Tissue From The Digestive Tract.
| Key Fact | Detail |
|---|---|
| Service Type | Surgery Surgical Procedures on the Digestive System |
| Common Place of Service | 22 - On Campus Outpatient Hospital 24 - Ambulatory Surgical Center |
| Common Modifiers | 59 - Distinct Procedural Service 51 - Multiple procedures |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $236.81 national non-facility rate (2026) · View Medicare rates for 43254 |
| Medicaid Fee Schedule | $192.13 median of the 8 states in the free preview · View Medicaid rates for 43254 |
National average reimbursement for CPT 43254 by major payers:
$360.88
$380.58
$395.24
$460.95
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CPT 43254
5 of 25 sample ratesHigher to lower in this preview
Lakeview Surgery Center Lc
$2,923.75Published rateSouthern Illinois Orthopedic Center,LLC
Southern Illinois Orthopedic Centerllc
$1,116.00Published rateIsurgery, LLC
Isurgery LLC
$750.00Published rateFleming Island Surgery Center
$630.00Published rateFriendship Surgery Center
$374.00Published rate
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See a sample payer proposalCPT 43254 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43254 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 43254 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 |
|---|---|---|
| 43248-CPT | Moderate | Upper Gastrointestinal Endosco, Upper Gastrointestinal Endoscopy Including Esophagusstomach And Either The Duodenum Andor Jejunumas Appropriate With Insertion Of Guide Wire Fol Lowed By |
| 43249-CPT | Moderate | Upper Gastrointestinal Endosco, Upper Gastrointestinal Endoscopy Including Esophagusstomach And Either The Duodenum Andor Jejunumas Appropriate With Balloon Dilation Of Esophag Us (Less Than |
| 43250-CPT | Moderate | Upper Gastrointestinal Endosco, Upper Gastrointestinal Endoscopy Including Esophagusstomach And Either The Duodenum Andor Jejunumas Appropriate With Removal Of Tumor(S) Polyp( S) Or Other |
| 43254-CPT | Moderate | Scope Exam Of Stomach, Exam Of The Esophagus Stomach And Intestines Using A Scope (Endoscope). The Procedure Includes Removing Tissue From The Digestive Tract. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43254. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43254 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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