Colonoscopy price: Medicare anchor and facility lever

What this procedure is, in price terms

Colonoscopy is billed under CPT 45378: Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) The code, not the marketing name, determines the Medicare anchor and the cash quote. If the order changes - for example with contrast instead of without, or a biopsy is added - the code changes and the price changes with it. Ask the ordering clinician's office to confirm the expected code before you price-shop, and ask the facility what code will be billed if the plan changes on the day.

What the price includes

• Endoscopist professional fee for the diagnostic procedure (PFS anchor below)
• Use of the endoscopy suite and standard recovery monitoring in the facility payment

What the price usually excludes

• Anesthesia or sedation billed separately (often CPT 45378 with anesthesia codes 00811 or 00812, or moderate sedation codes)
• Pathology when a biopsy or polyp is taken (for example 88305)
• Bowel prep supplies
• The pre-procedure visit and follow-up visit when billed separately

A quote is complete only when it states which of the excluded items apply to you and what each costs. Get that in writing.

Why prices vary for CPT 45378

Colonoscopy has three price layers that move independently: the endoscopist professional fee, the facility fee (hospital OPPS versus ASC versus office), and anesthesia and pathology when they apply. Medicare pays the professional fee under the PFS at a lower facility rate when the work is done in a facility, because the facility bears the overhead. The facility fee is the largest lever. A hospital outpatient department is paid under OPPS, an ambulatory surgery center under the ASC system at a lower rate, and an office endoscopy suite under the PFS nonfacility amount with no separate facility bill.

Geography also matters. Physician Fee Schedule amounts are locality-adjusted, so the Michigan Locality 01 anchor on this page will differ somewhat from the amount in another locality. OPPS amounts are national unadjusted rates before the hospital wage index is applied. Use the anchor for order of magnitude and for the facility comparison, not as a prediction of your bill.

The facility-type lever

Ask where the procedure will be performed (hospital, ASC, or office), whether anesthesia will bill separately, and whether pathology is likely. Get the all-in cash quote for each layer in writing.

Compare the same CPT code in more than one setting when your clinician allows a choice:

• Hospital Outpatient Department - OPPS (APC-based facility payment) + Physician Fee Schedule professional fee. Facility fee: Yes - separate OPPS facility payment to the hospital.
• Ambulatory Surgery Center - ASC payment system (procedure-based, generally below OPPS) + Physician Fee Schedule professional fee. Facility fee: Yes - ASC facility fee, typically lower than hospital OPPS for the same procedure.
• Independent Imaging Center - Physician Fee Schedule global payment when the center owns the equipment and employs or contracts the radiologist. Facility fee: No separate hospital facility fee - the technical component is inside the global PFS payment.
• Physician Office - Physician Fee Schedule nonfacility payment (higher practice-expense component than facility rate). Facility fee: No separate facility fee - office overhead is inside the nonfacility PFS rate.

Use the Price Anchor Explorer to see how the anchor presentation changes by facility type.

Self-pay ranges on this page

Self-pay ranges are not published yet for Colonoscopy. MyCarePrice adds a self-pay range only where it can be verified from a public source under Procedure Price Method v1.0. Until then, this page ships the verified Medicare anchor plus facility-type education. That is deliberate: an invented range would be worse than no range.

To get a real self-pay number today, ask the facility directly: "What is the all-in cash price for CPT 45378, including professional, facility, anesthesia, and pathology if they apply?" See How to ask for the cash price and Questions to ask billing before your procedure.

Questions to ask before you book

1. What CPT code will be billed if nothing changes, and what code will be billed if the plan changes?
2. Is the quote global, or will the professional fee bill separately?
3. What setting is this price for, and what would the same code cost in the other setting you offer?
4. Are anesthesia and pathology included, likely, or billed separately?
5. Can I have the all-in price in writing, with the code, setting, and inclusions listed?

Frequently asked questions

Sources and verification