BACKGROUND: A detailed analysis of the costs of ERCP is needed to provide medical staff, hospital administrators, and health care insurers with a solid basis for decision making. METHODS: An incremental cost analysis was performed from the hospital perspective. Cost calculations were based on a prospective registration of materials, labor time, and equipment needed to perform 204 ERCPs in a tertiary care center. RESULTS: Annual fixed cost related to the organization of the ERCP-unit amounted to $136,213. Variable costs per procedure, including labor and material costs, amounted to $344 and $961 for diagnostic and therapeutic procedures, respectively. Average reimbursement was $221. For the actual situation in our unit, with about 900 procedures yearly and a ratio diagnostic versus therapeutic procedures of 35 to 65, a net yearly loss because of the performance of ERCP activities amounts to $608,038. Theoretical measures to decrease costs could reduce this loss to $394,798, with an average loss of $439 per procedure. CONCLUSIONS: This analysis of costs related to performance of ERCPs clearly shows that ERCP is not sufficiently reimbursed. From our model, it appears that increasing the reimbursement rate for therapeutic procedures to $600 per procedure would generate a net positive balance.