Medicare reimbursement reference

CPT 43249: $1228

EGD with dilation by balloon. The federally-set baseline for what this code costs when Medicare pays — the standard public-domain reference for self-pay or insured bill review.

Data updated 35 days ago·verified today·Source: CMS Physician Fee Schedule

National average

$1228

Per CMS Physician Fee Schedule, effective 2026-01-01. Non-facility national-average. Real Medicare payments adjust by ±15% based on Geographic Practice Cost Index.

What CPT 43249 actually is

EGD with dilation by balloon (CPT 43249). This code falls in the "Procedure" service family. Medicare's national-average non-facility allowed amount is the federally-set baseline; commercial insurance and hospital cash-pay rates often run multiples of this number for the same code, depending on the facility and contract.

The number above is one piece of context. The other two benchmarks worth knowing:

  • Hospital cash-pay rate

    Federally required to be published by every US hospital under 45 CFR §180.50 (the Hospital Price Transparency rule). The hospital’s own machine-readable file is the authoritative source. Same code; rates vary widely by facility.

  • Insurance-negotiated rate

    Whatever your specific insurance plan and the specific facility have contracted for the same code. Visible on your Explanation of Benefits (EOB) after the claim posts.

  • Medicare allowed amount (this page)

    $1228 for code 43249, set in federal law and updated annually by CMS. Used as the floor benchmark in most bill-review work.

Where CPT 43249 commonly shows up on a bill

Common patterns to look at when reviewing this code:

  • 01.Surgery codes billed alongside the components they already include — the CMS global package generally bundles pre-op visits and routine post-op care into the surgical fee.
  • 02.Bilateral procedures billed twice instead of once with the bilateral modifier (-50).
  • 03.Co-surgeons or assistants billed at full fee where federal rules allow only a percentage.

These patterns are documented in CMS billing guidance, the National Correct Coding Initiative (NCCI) edits, and Office of Inspector General audit reports. None of them are accusations about any specific bill or facility — they’re the checks that exist because the patterns themselves exist.

What hospitals charge for CPT 43249

Distribution across 61 US hospitals reporting this code under federal Hospital Price Transparency rules (45 CFR §180.50). Gross charges shown here are the chargemaster prices — the starting point before insurance discounts or self-pay reductions. Medicare allowed amount: $1228.

Hospital gross (median)

$5,255

25th $2,556 · 75th $8,267

Cash / self-pay (median)

$2,422

What hospitals accept directly

Commercial (median)

$1,594

Range $98–$30,755

Medicare allowed

$1,228

Federal-rate floor

Range across all reporting hospitals: $393 to $48,002. That’s a 122× spread for the same procedure code — one of the reasons federal price-transparency rules exist.

Hospitals at the lower end of the distribution

Sorted by published chargemaster price only. Chargemaster is the starting point before insurance discounts or self-pay reductions; the actual amount any specific patient pays depends on case mix, charity-care policy, and insurance contract.

If your bill has this code

See exactly how your charge compares to $1228— in just a few minutes.

Upload a photo or PDF of your bill. Our system reads every line, compares each charge to six federal data sources (CMS PFS, NADAC drug benchmarks, federally-required Hospital Price Transparency files, the National Correct Coding Initiative, CMS Hospital Compare quality data, and IRS Publication 78 for charity-care eligibility), and drafts dispute letters for anything worth questioning — with the codes, the math, and the federal-law citations already inside.

  • ✓Line-by-line audit, every charge benchmarked.
  • ✓Up to 5 dispute letters drafted — sign and mail.
  • ✓Charity-care application if your hospital is non-profit.
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Related codes

Codes in the same numerical neighborhood — often appear together on the same bill or get billed in place of each other:

Common questions about CPT 43249

How much does CPT 43249 cost?
Medicare's national-average non-facility allowed amount for CPT 43249 is approximately $1228 as of 2026-01-01. Hospital cash-pay rates and commercial-insurance contracted rates for the same code are typically higher; the gap is what most billing reviews focus on.
Why is my CPT 43249 bill higher than $1228?
Three common reasons: (1) the rate above is non-facility — bills from inpatient hospital settings can be paid differently, (2) commercial insurance contracts and hospital chargemasters are not bound by Medicare rates and often run several multiples higher, and (3) modifiers on the bill may add or subtract from the base rate. The federally-mandated Hospital Price Transparency file for the facility that billed you is the authoritative source for the cash-pay and insurance-negotiated rates at that specific hospital.
Can I dispute a CPT 43249 charge?
Yes. Federal and state consumer-protection law gives every patient the right to (1) request an itemized statement (HIPAA §164.524), (2) receive a Good Faith Estimate before scheduled service (No Surprises Act, 2022), (3) dispute amounts billed without prior consent or proper notice, and (4) apply for charity care if the facility is a 501(c)(3) non-profit (ACA §501(r)). The benchmark above is one piece of evidence; the hospital's own HPT file is another.
What's the source of this number?
The CMS Physician Fee Schedule (PFS) — published annually by the Centers for Medicare & Medicaid Services and required by 42 USC §1395w-4 to be publicly available. We refresh from CMS quarterly. Last updated: 2026-01-01.

P.S. If you’re holding a bill with code 43249on it right now, the fastest path is to run it through the audit — it takes just a few minutes and shows the exact gap between what was charged and the $1228 benchmark above. Start the audit →

P.P.S. If the bill came from a non-profit hospital, federal law (ACA §501(r)) requires them to offer charity care to patients below specific income thresholds. We auto-check 501(c)(3) status against the IRS Publication 78 database and draft the application letter when applicable.

P.P.P.S. The $1228number above is a benchmark, not a verdict. The right question on any specific bill is whether the documentation in your medical record supports the code that was billed — that’s what every bill-review process ultimately comes down to.

Source & methodology

Rate from the CMS Physician Fee Schedule, refreshed quarterly from cms.gov. National-average non-facility allowed amount; real Medicare payment adjusts by ±15% per locality (GPCI). The CMS PFS is in the public domain (17 USC §105). Full data-source register at /data-sources.