CPT 43264 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 | Endoscopic Retrograde Cholangiopancreatography (ERCP) Procedures Endoscopy Procedures on the Esophagus |
| Common Place of Service | 21 - Inpatient Hospital 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 43264 |
National average reimbursement for CPT 43264 by major payers:
$512.54
$557.61
$589.74
$644.71
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
United | 43264 | $830.00 | 1013048461 - GASTROENTEROLOGY DIAGNOSTIC CENTER MEDICAL GROUP, A PROFESSIONAL, GASTROENTEROLOGY DIAGNOSTIC CENTER | 953921090 - (CA) GASTROENTEROLOGY DIAGNOSTIC CENTER MEDICAL GROUP A PROFESSIONAL | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $850.00 | 1013341734 - CENTER FOR PAIN AND SPINE, LLC | 814348805 | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1225.00 | 1972030161 - ADVANCED VISION SURGERY CENTER LLC | 820697854 - (CO) ADVANCED VISION SURGERY CENTER LLC | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $2717.00 | 1972541415 - OCEAN ENDOSURGERY CENTER LLC, OCEAN ENDOSURGERY CENTER | 223564617 - (NJ) OCEAN ENDOSURGERY CENTER LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $2717.00 | 1942267893 - GASTROENTEROLOGY DIAGNOSTICS OF NORTHERN NEW JERSEY, PA | 223345724 - (NJ) GASTROENTEROLOGY DIAGNOSTICS OF NORTHERN NEW JERSEY, P.A. | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $2965.00 | 1326309394 - ADVANCED SURGERY CENTER OF ORLANDO LLC | 453785008 - (FL) ADVANCED SURGERY CENTER OF ORLANDO LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1445.00 | 1508810656 - RETINAL AMBULATORY SURGERY CENTER OF NEW YORK, INC. | 134189700 - (NY) RETINAL AMBULATORY SURGERY CENTER OF NY, INC. | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $530.00 | 1023039195 - CAPE SURGERY CENTER, LLC | 200649544 - (TN) CAPE SURGERY CENTER LLC | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $868.00 | 1710924881 - GEORGIA DERMASURGERY CENTERS, INC. | 582495671 - (GA) GEORGIA DERMASURGERY CENTERS INC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1274.00 | 1699421024 - INFIRMARY ASC | 87192233 | AL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $600.00 | 1992941462 - NORTHWEST ENDOSCOPY CENTER, LLC, NORTH WEST ENDOSCOPY CENTER | 364644974 - (GA) NORTHWEST ENDOSCOPY CENTER LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1094.00 | 1306187554 - EYE SURGERY CENTER OF WEST GEORGIA LLC | 455011801 - (GA) EYE SURGERY CENTER OF WEST GEORGIA LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1786.00 | 1871513705 - SQUAW PEAK SURGICAL FACILITY INC | 860889294 - (AZ) SQUAW PEAK SURGICAL FACILITY INC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1750.00 | 1851865828 - ATLANTA SURGERY NORTH | 832134639 - (GA) ATLANTA SURGERY NORTH | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1090.00 | 1295385482 - JOHNS HOPKINS SURGERY CENTERS SERIES | 208707724 - (MD) JOHNS HOPKINS SURGERY CENTER SERIES | MD | 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 43264 vs. Other Endoscopy Procedures on the Esophagus Codes
The CPT 43264 code is part of the Endoscopic Retrograde Cholangiopancreatography (ERCP) Procedures services used for Endoscopy Procedures on the Esophagus. 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 43264 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 |
|---|---|---|
| 43260-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); Diagnostic Including Collection Of Specimen(S) By Brushing Or Washing When Performed(Separate Procedure) (Revised 01/01/2014) |
| 43261-CPT | Moderate | Scope Exam Of Bile Ducts, Examination Of The Bile Ducts And Pancreatic Ducts Using A Scope. The Procedure Removes A Sample Of Tissue For Testing. |
| 43262-CPT | Moderate | Scope Exam Of Bile Ducts, Examination Of The Bile Ducts And Pancreatic Ducts Using A Scope. The Procedure Includes Cutting Of A Sphincter (Band Of Muscle Around An Opening) To Free The Flow Of Bile Blocked By A Gallstone Or Other Material. |
| 43264-CPT | Moderate | Endoscopic Retrograde Cholangi, Endoscopic Retrograde Cholangiopancreatography (Ercp) With Endoscopic Retrograde Removal Of Stone(S) From Biliary Andor Pancreatic Ducts |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43264. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43264 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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