Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope in Pennsylvania

Pennsylvania Pricing in Context

In Pennsylvania, CPT code 42975 (Evaluation Of Sleep-Disordered Breathing By Examination Of Upper Airway Using An Endoscope) carries an average Medicare payment of $67.45 — 6% above the national benchmark of $63.69. 58 providers across the state submitted claims for this procedure in 2023, performing 446 total services. Individual payments in PA ranged from N/A at the low end to N/A at the high end, reflecting differences in provider setting (office vs. facility), modifiers, and the specific geographic locality code applied within the state.

The average billed charge in Pennsylvania is $581.52, which is the figure uninsured patients would most likely encounter before any negotiation or charity discount. Medicare, by statute, only reimburses the allowed amount — the balance between billed and paid is written off under provider participation agreements. Insured patients generally pay a negotiated rate that falls between these two figures; the exact amount depends on plan design, deductible status, and in-network participation. Because Pennsylvania sits above the national Medicare average, commercial rates in the state may also run higher than the US median.

Using RAND 2024 commercial-to-Medicare ratios for Digestive Surgery procedures, the estimated commercial insurance price in Pennsylvania lands near $202.20, with self-pay cash prices typically around $228.85. Before scheduling, patients can request a Good Faith Estimate under the No Surprises Act, compare cash rates from hospital Machine-Readable Files, and confirm whether the provider is in-network with their specific plan. This page presents CMS reference data for informational use; it does not constitute medical or financial advice.