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See a sample rate comparisonCPT 43264 Fee Schedule
Last Verified: September 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.
Endoscopic Retrograde Cholangi, Endoscopic Retrograde Cholangiopancreatography (Ercp) With Endoscopic Retrograde Removal Of Stone(S) From Biliary Andor Pancreatic Ducts
| Key Fact | Detail |
|---|---|
| Service Type | Surgery Surgical Procedures on the Digestive System |
| 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 |
| Medicaid Fee Schedule | View Medicaid rates for 43264 |
National average reimbursement for CPT 43264 by major payers:
$512.54
$557.61
$589.74
$644.71
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CPT 43264
5 of 25 sample ratesHigher to lower in this preview
Ku Medwest Ambulatory Surgery Center, LLC
Ku Medwest Ambulatory Surgery Center LLC
$4,405.00Published rateBsc 3 LLC, Banner Surgery Center - Sports Medicine
Bsc 3 LLC
$2,007.00Published rateInfirmary Asc
$1,274.00Published rateGeorgia Dermasurgery Centers, Inc.
Georgia Dermasurgery Centers Inc
$868.00Published rateThe Surgery & Endoscopy Center LLC
The Surgery Endoscopy Center LLC
$390.00Published rate
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See a sample payer proposalCPT 43264 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43264 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 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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