Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope
What Medicare pays for 42975, what providers bill, and how the price varies across 50 states, drawn from CMS 2023 claims data.
42975 · the short answer
For evaluation of sleep-disordered breathing by examination of upper airway using an endoscope, Medicare pays about $63.69 while providers bill $1,020.08 on average, a 16.0× markup, one of the steepest markups in the catalog. State-level Medicare rates range 73% from lowest to highest.
- Medicare pays
- $63.69
- Providers bill
- $1,020.08
- Markup
- 16.0×
- Markup percentile
- 98th
Medicare amounts are CMS-published; markup = average submitted charge ÷ average Medicare payment.
Price Range Across States
What You Might Pay
Estimated using RAND 2024 commercial-to-Medicare ratios. Actual prices vary by insurer, plan, and facility.
How we estimate these prices
These estimates are based on the RAND Hospital Price Transparency Study (4th Edition, 2024), which found that commercial insurance prices average 224% of Medicare rates nationally. We apply category-specific ratios: Digestive Surgery procedures average 2.24x Medicare rates. Cash/self-pay estimates blend typical cash discounts (55% of billed charges) with Medicare-based estimates (150% of allowed amounts). These are statistical estimates, not quotes. Contact your insurer or provider for actual costs.
Where this markup sits nationally
Markup (billed ÷ Medicare) across 8,901 procedures with a meaningful Medicare rate
16 Among the most affordable more affordable than 98% of 8,901 procedures
Each bar is a band; taller bars hold more procedures. The dashed line + filled bar mark this entry. Hover or tap any bar for its full count, share, and where it sits relative to this entry.
Source CMS Medicare Physician & Other Practitioners · 2023
Prices by State
| State | Medicare Payment | Billed Charge |
|---|---|---|
| Alaska | $81.35 | $1,708.02 |
| District of Columbia | $76.97 | $512.05 |
| New York | $76.71 | $615.89 |
| Delaware | $76.32 | $305.65 |
| Rhode Island | $76.25 | $777.78 |
| Maryland | $74.35 | $1,609.64 |
| Connecticut | $74.26 | $1,612.86 |
| Massachusetts | $73.90 | $548.81 |
| New Hampshire | $73.74 | $821.98 |
| New Jersey | $72.91 | $2,401.46 |
| West Virginia | $72.01 | $303.43 |
| Wyoming | $71.87 | $1,304.73 |
| Nevada | $70.86 | $806.08 |
| Maine | $68.77 | $234.08 |
| Ohio | $68.22 | $959.94 |
| Kentucky | $68.14 | $973.60 |
| California | $68.03 | $1,349.78 |
| Michigan | $67.99 | $442.15 |
| Pennsylvania | $67.45 | $581.52 |
| Virginia | $67.22 | $873.90 |
| North Dakota | $66.10 | $287.88 |
| Illinois | $66.08 | $1,027.60 |
| Florida | $65.46 | $921.11 |
| North Carolina | $64.73 | $543.88 |
| Missouri | $64.52 | $1,241.41 |
| Georgia | $64.31 | $468.12 |
| Utah | $63.74 | $860.75 |
| Wisconsin | $63.68 | $1,696.23 |
| Oklahoma | $62.65 | $362.83 |
| South Carolina | $62.19 | $369.08 |
| Iowa | $62.19 | $941.05 |
| Minnesota | $61.66 | $910.73 |
| Colorado | $61.05 | $876.06 |
| Texas | $61.04 | $1,402.28 |
| Arizona | $60.46 | $2,716.40 |
| South Dakota | $59.88 | $470.73 |
| Oregon | $58.72 | $460.76 |
| New Mexico | $58.60 | $735.33 |
| Arkansas | $58.25 | $199.61 |
| Washington | $58.10 | $424.33 |
| Louisiana | $58.10 | $431.34 |
| Hawaii | $58.06 | $534.86 |
| Tennessee | $58.01 | $543.77 |
| Nebraska | $57.00 | $681.35 |
| Indiana | $54.76 | $1,980.57 |
| Kansas | $53.73 | $1,464.11 |
| Mississippi | $49.91 | $426.99 |
| Idaho | $49.78 | $356.20 |
| Alabama | $49.23 | $636.70 |
| Montana | $46.96 | $320.67 |
What the Data Says About Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope
Across 50 states with reporting providers, CPT code 42975 (Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope) shows a national average Medicare payment of $63.69 against an average billed charge of $1,020.08. That gap, a 16.0x markup, or 1502% above the Medicare allowed amount, sits among the widest billed-to-paid spreads we track, the kind of chargemaster pricing almost no payer, insured or cash, actually honors in full.
Digestive Surgery procedures like this one saw 11.1K services billed to Medicare in 2023 by 1.4K distinct providers, serving 9.0K unique beneficiaries. State-level variation is significant: Montana reports the lowest average payment at $46.96, while Alaska reports the highest at $81.35. A 73% spread this wide is typically a GPCI story: practice-expense and malpractice-premium components of the fee formula diverge sharply by locality even though the procedure code never changes.
Applying RAND 2024 commercial-to-Medicare ratios specific to the Digestive Surgery category (2.24x), the estimated commercial insurance price lands near $186.71, with self-pay cash discounts commonly bringing the figure closer to $343.04. Within Digestive Surgery, Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope ranks #737 of 765 tracked procedures by national average Medicare payment.
What to do with this
If you may have evaluation of sleep-disordered breathing by examination of upper airway using an endoscope done, these steps turn the numbers above into a real-world cost estimate.
- Request a Good Faith Estimate from your provider at least 3 business days before a scheduled procedure, under the No Surprises Act it is an enforceable written price.
- Compare evaluation of sleep-disordered breathing by examination of upper airway using an endoscope costs in your state, Medicare rates vary by locality. Browse states
- Check a hospital’s published cash price, which is often far below the billed charge. Price transparency
- Understand why billed charges run several times the Medicare rate before you negotiate. Read the guide
Figures here are averages and estimates, not a quote. Confirm coverage and out-of-pocket costs with your insurer and provider.
Frequently Asked Questions
How much does Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope cost?
Medicare's national average payment for Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope (CPT 42975) is $63.69, with providers billing $1,020.08 on average; state rates run from $46.96 to $81.35, a meaningful but not extreme spread.
Why do providers charge more than Medicare pays?
Providers set their own chargemaster rates (billed charges), which are typically much higher than what any insurer pays. Medicare pays a fixed rate based on the procedure code and geographic location. The billed charge is relevant mainly for uninsured patients, who may face prices closer to the submitted charge.
How much does Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope cost with insurance?
With commercial insurance, evaluation of sleep-disordered breathing by examination of upper airway using an endoscope costs an estimated $186.71 on average (range: $130.69-$261.39), a moderate premium over Medicare's $63.69. Without insurance, the estimated cash price is $343.04.
Which state has the lowest cost for Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope?
Montana has the lowest average Medicare payment for Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope at $46.96, while Alaska has the highest at $81.35 - a meaningful $34.39 spread.
How many providers perform Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope?
A moderate provider base performs Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope: 1.4K providers nationally, totaling 11.1K Medicare-billed services (9.0K beneficiaries) across 50 states in 2023.
What is the billed-to-Medicare markup for Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope?
Providers bill 16.0x what Medicare pays for Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope - one of the steepest markups in the catalog at 1502% above the Medicare rate.
Related Guides
Tips to reduce out-of-pocket costs
Your right to upfront pricing
How Medicare payments work
Decode charges and codes
Why bills exceed actual costs
Geographic pricing factors
Data from CMS Medicare Physician & Other Practitioners (2023).
Read our methodology - how this data is sourced, computed, and verified.
Related
Every figure on PlainProcedure is rendered directly from CMS Medicare Physician & Other Practitioners data, no number is typed in by an editor. This page draws directly on CMS Medicare Physician & Other Practitioners data, no figure is typed in by an editor. See our editorial standards & corrections policy, the methodology behind these numbers, or report a data error.