Paying for upper endoscopy in the US
Examination of the esophagus, stomach and duodenum (EGD). Four routes can pay for it: Original Medicare, Medicaid, employer or Marketplace insurance, and paying the provider yourself. The table sets out what each route covers and the price, with the source of every figure and the date it was read. Where a route publishes nothing, or this site has not read it, the cell says so.
How each route pays for upper endoscopy
| Route | What it covers | Wait | Payment or price | Source |
|---|---|---|---|---|
| Original Medicare (Part B)CPT 43235: EGD diagnostic | Patient usually pays 20%of the Medicare-approved amount, after the Part B deductible, where the provider accepts that amount as full payment | Not publishedNo official US source publishes waiting times for elective care | $110.56What Medicare pays the clinician when the procedure is done in a hospital or surgery center, national amount. The surgery center’s facility payment is separate ($497.85, listed below). Not a patient price. |
|
| MedicaidRun by each state within federal rules | Not trackedCoverage is set by each state; no state’s Medicaid rules for upper endoscopy have been read | Not publishedNo official US source publishes waiting times for elective care | Not trackedNo state Medicaid payment or cost-sharing has been read | None for this row |
| Employer or Marketplace insuranceAs a mechanism; no insurer, plan or premium is named | Set by each plan’s terms71% of workers with employer coverage are in self-funded plans (KFF Employer Health Benefits Survey 2026), where the employer pays claims from its own funds. | Not publishedNo official US source publishes waiting times for elective care | Up to $10,600 a yearFederal cap on in-network cost-sharing for an individual on a Marketplace plan, plan year 2026 (family: $21,200). Excludes premiums, services the plan does not cover and out-of-network care. |
|
| Self-pay at a hospitalDiscounted cash price, CPT 43235, facility charge | The hospital’s facility charge for the service; professional fees are a separate billing class, not includedYou are entitled to a Good Faith Estimate of expected charges when you book or ask (45 CFR 149.610) | Not publishedNo official US source publishes waiting times for elective care | $2,187Median of 23 hospitals’ published cash prices, $426–$14,673. Files read 26 October 2026. |
|
- Waits: no official US source publishes waiting times for elective care, so none is shown for any route.
- The Part B deductible is $283 for calendar year 2026 (CMS: 2026 Medicare Parts A & B Premiums and Deductibles, read 26 October 2026). The patient's share is not calculated here: it depends on the deductible already paid, the setting, and any separate facility charge.
- For plan choice within Medicare, including any plan other than Original Medicare, see Medicare.gov. TreatCompare does not name, compare or price plans.
- Figures from different routes are not added together or compared as one bill. What Medicare pays, an insurance cap and a provider's self-pay price each describe a different thing.
Every billing code for upper endoscopy, one at a time
Each billing code is a different service at its own price, so codes are never averaged together. This is what Medicare pays under its national fee schedule, before geographic adjustment. It is not a price charged to patients or to anyone without Medicare. Hospital cash prices and negotiated rates are separate figures from the same files: the first is what the hospital charges a self-pay patient, the second what insurers have agreed to pay it, shown with no payer named.
| Code and service | What Medicare pays: office | What Medicare pays: clinician, in a facility | What Medicare pays: surgery center | Hospital cash price | Hospital negotiated rates |
|---|---|---|---|---|---|
| 43235EGD diagnostic | $322.65 | $110.56 | $497.85 | $2,187median of 23 hospitals, $426–$14,6739 more list several charge lines and are not counted | $1,632median of 41 hospitals, $616–$13,697; rates from 696 payer–hospital pairs, no payer named9 more list several charge lines and are not counted |
| 43239EGD with biopsy | $418.85 | $123.58 | $497.85 | $2,699median of 26 hospitals, $320–$14,4247 more list several charge lines and are not counted | $1,589median of 44 hospitals, $616–$14,262; rates from 834 payer–hospital pairs, no payer named7 more list several charge lines and are not counted |
| 43249EGD with dilation | $1,180.39 | $136.28 | $894.33 | $3,191median of 24 hospitals, $325–$17,7295 more list several charge lines and are not counted | $2,363median of 46 hospitals, $1,131–$14,262; rates from 857 payer–hospital pairs, no payer named5 more list several charge lines and are not counted |
- Medicare amounts: CMS Physician Fee Schedule relative value file RVU26D, read 26 October 2026; surgery center rates: CMS ambulatory surgical center payment rates, Addendum AA, October 2026, read 26 October 2026. Service labels are TreatCompare's plain-English wording, not CMS or AMA descriptors.
- CMS's note on the surgery center rates, as printed: “NOTE 3: The Medicare program payment is 80 percent of the total payment amount and beneficiary coinsurance is 20 percent of the total payment amount except for most preventive services. Sections 4104 and 10406 of the Affordable Care Act (ACA) waive coinsurance and the Part B deductible for most preventive services. These preventive services are identified with a double asterisk (**).”
- Hospital figures are facility charges from each hospital's own standard-charge file. A hospital whose file lists several different charge lines for one code is named but not counted, because no single line is the service. Hospitals on one file host publishing the same figure count once.
The hospital files behind the self-pay figure (CPT 43235)
Each hospital's discounted cash price for CPT 43235 (EGD diagnostic), from its own file, A to Z, with the date the file was read.
| Hospital | State | Cash price | File |
|---|---|---|---|
| AdventHealth Orlando | FL | $3,055 | Standard-charge fileread 26 October 2026 |
| Cleveland Clinic Florida | FL | $3,504 | Standard-charge fileread 26 October 2026 |
| Cleveland Clinic Main Campus | OH | $2,803 | Standard-charge fileread 26 October 2026 |
| Corewell Health Butterworth Hospital | MI | $867 | Standard-charge fileread 26 October 2026 |
| Denver Health Medical Center | CO | $565 | Standard-charge fileread 26 October 2026 |
| Duke University Hospital | NC | $813 | Standard-charge fileread 26 October 2026 |
| Froedtert Hospital | WI | $1,554 | Standard-charge fileread 26 October 2026 |
| Grady Memorial Hospital | GA | $3,678 | Standard-charge fileread 26 October 2026 |
| Houston Methodist Hospital | TX | $426 | Standard-charge fileread 26 October 2026 |
| Lovelace Medical Center | NM | $1,220 | Standard-charge fileread 26 October 2026 |
| Memorial Medical Center Las Cruces | NM | $7,325 | Standard-charge fileread 26 October 2026 |
| MercyOne Des Moines Medical Center | IA | $14,673 | Standard-charge fileread 26 October 2026 |
| Saint Francis Hospital and Medical Center | CT | $6,671 | Standard-charge fileread 26 October 2026 |
| Stanford Hospital | CA | $3,788 | Standard-charge fileread 26 October 2026 |
| Tampa General Hospital | FL | $502 | Standard-charge fileread 26 October 2026 |
| The Mount Sinai Hospital | NY | $2,187 | Standard-charge fileread 26 October 2026 |
| UCHealth University of Colorado Hospital | CO | $1,425 | Standard-charge fileread 26 October 2026 |
| UCSF Medical Center | CA | $869 | Standard-charge fileread 26 October 2026 |
| UnityPoint Health - Meriter | WI | $3,541 | Standard-charge fileread 26 October 2026 |
| UnityPoint Health Iowa Lutheran HospitalSame figure, same file host: UnityPoint Health Iowa Methodist Medical Center | IA | $1,610 | Standard-charge fileread 26 October 2026 |
| University of Iowa Hospitals & Clinics | IA | $2,383 | Standard-charge fileread 26 October 2026 |
| UPMC Presbyterian | PA | $3,236 | Standard-charge fileread 26 October 2026 |
| UT Southwestern University Hospitals | TX | $1,526 | Standard-charge fileread 26 October 2026 |
Not counted, because the file lists several charge lines for this code: Hospital of the University of Pennsylvania (PA, 2 lines); M Health Fairview University of Minnesota Medical Center (MN, 4 lines); Mercy Hospital Oklahoma City (OK, 2 lines); Mercy Hospital St. Louis (MO, 4 lines); OU Health University of Oklahoma Medical Center (OK, 5 lines); Providence St. Vincent Medical Center (OR, 2 lines); Swedish Medical Center First Hill (WA, 3 lines); Thomas Jefferson University Hospital (PA, 2 lines); University of Chicago Medical Center (IL, 4 lines).
Paying yourself: the Good Faith Estimate
Providers and facilities must give uninsured and self-pay patients a Good Faith Estimate of expected charges when a service is scheduled or on request.
Source: eCFR: 45 CFR 149.610, In force (45 CFR 149.610, text as of 2026-10-01), read 26 October 2026.
More on upper endoscopy in the US
Sources
- CMS Physician Fee Schedule relative value file RVU26D, 2026 national amounts. Read 26 October 2026. What Medicare pays, national amounts, per code.
- CMS ambulatory surgical center payment rates, Addendum AA, October 2026, October 2026. Read 26 October 2026. What Medicare pays a surgery center, per code.
- CMS: 2026 Medicare Parts A & B Premiums and Deductibles, Calendar year 2026. Read 26 October 2026. Part B annual deductible.
- eCFR: 45 CFR 149.610, In force (45 CFR 149.610, text as of 2026-10-01). Read 26 October 2026. The Good Faith Estimate rule.
- Medicare.gov: Medicare costs, In force (statutory share; not set annually). Read 26 October 2026.
- KFF: 2026 Employer Health Benefits Survey, KFF Employer Health Benefits Survey 2026. Read 26 October 2026.
- HealthCare.gov glossary: out-of-pocket maximum/limit, Plan year 2026. Read 26 October 2026.