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 | • 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 |
| CMS | $347.40 Physician Fee Schedule |
National average reimbursement for CPT 43264 by major payers:
$512.54
$557.61
$589.74
$659.05
| 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 43264 | ||||||
United | 43264 | $1300.00 | 1578088787 - VACCO LLC | 821221738 - (OH) VACCO LLC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1695.00 | 1396896684 - DREYER AMBULATORY SURGERY CENTER, LLC | 363890298 - (IL) DREYER AMBULATORY SURGERY CENTER LLC | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $4141.00 | 1538104724 - FORT WORTH ENDOSCOPY CENTERS, LLC, SOUTHWEST FORT WORTH ENDOSCOPY CENTER | 770368346 - (TX) FORT WORTH ENDOSCOPY CENTERS LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
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 | $1660.00 | 1376884585 - ADVANCED UROLOGY SURGERY CENTER | 461456287 - (GA) ADVANCED UROLOGY SURGERY CENTER | GA | 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 | $900.00 | 1790742328 - SPRINGHILL SURGERY CENTER, LLC | 621712554 - (AR) SPRINGHILL SURGERY CENTER, LLC | AR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1074.00 | 1043497019 - PIKESVILLE MD ENDOSCOPY ASC LLC, ENDOCENTRE OF BALTIMORE | 261467040 | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $1300.00 | 1962661884 - ACD-SA, LTD., SENDERO IMAGING AND TREATMENT CENTER | 742822681 | TX | 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 | $1514.00 | 1619144607 - PACIFIC CATARACT AND LASER INSTITUTE, INC., P.C. | 911394965 - PACIFIC CATARACT AND LASER INSTITUTE, INC., PC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $2353.00 | 1053764779 - SURGCENTER OF ST. LUCIE, LLC | 475425011 - (FL) SURGCENTER OF ST. LUCIE, LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43264 | $2388.00 | 1295060069 - TIMONIUM SURGERY CENTER, LLC | 270399689 - (MD) TIMONIUM SURGERY CENTER LLC | MD | 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 | $710.00 | 1760423180 - CENTRAL COAST ENDOSCOPY CENTER INC | 770456846 - (CA) CENTRAL COAST ENDOSCOPY CENTER INC | CA | 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 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 | Ercp; With Biopsy, Single Or Multiple |
| 43262-CPT | Moderate | Ercp,W/Wo Bx/Coll.Specimen;Sphincterotom |
| 43264-CPT | Moderate | Endoscopic Retrograde Cholangiopancreatography (Ercp); With Removal Of Calculi/Debris From Biliary/Pancreatic Duct(S) (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 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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