Severing Of Muscle At Stomach Outlet To Upper Small Bowel
What Medicare pays for 43520, what providers bill, and how the price varies across 1 states, drawn from CMS 2023 claims data.
43520 · the short answer
For severing of muscle at stomach outlet to upper small bowel, Medicare pays about $335.56 while providers bill $2,498.86 on average, a 7.4× markup, a higher-than-typical markup. State-level Medicare rates range 0% from lowest to highest.
- Medicare pays
- $335.56
- Providers bill
- $2,498.86
- Markup
- 7.4×
- Markup percentile
- 75th
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
7 Among the most affordable more affordable than 75% 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 |
|---|---|---|
| Florida | $360.14 | $2,716.42 |
What the Data Says About Severing Of Muscle At Stomach Outlet To Upper Small Bowel
Across 1 states with reporting providers, CPT code 43520 (Severing Of Muscle At Stomach Outlet To Upper Small Bowel) shows a national average Medicare payment of $335.56 against an average billed charge of $2,498.86. That gap, a 7.4x markup, or 645% above the Medicare allowed amount, runs well above the median for tracked procedures, a sign the chargemaster rate here is more aspirational than transactional.
Digestive Surgery procedures like this one saw 81 services billed to Medicare in 2023 by 54 distinct providers, serving 71 unique beneficiaries. Regional variation is limited in the underlying CMS file. At just 0%, this procedure prices remarkably consistently nationwide, GPCI adjustments barely move the needle for this particular code.
Applying RAND 2024 commercial-to-Medicare ratios specific to the Digestive Surgery category (2.24x), the estimated commercial insurance price lands near $940.83, with self-pay cash discounts commonly bringing the figure closer to $1,002.20. Within Digestive Surgery, Severing Of Muscle At Stomach Outlet To Upper Small Bowel ranks #383 of 765 tracked procedures by national average Medicare payment.
What to do with this
If you may have severing of muscle at stomach outlet to upper small bowel 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 severing of muscle at stomach outlet to upper small bowel 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 Severing Of Muscle At Stomach Outlet To Upper Small Bowel cost?
Severing Of Muscle At Stomach Outlet To Upper Small Bowel (CPT 43520) is priced fairly consistently nationwide: Medicare pays $335.56 on average, and the $360.14-$360.14 state range stays relatively tight. Providers typically bill $2,498.86.
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 Severing Of Muscle At Stomach Outlet To Upper Small Bowel cost with insurance?
With commercial insurance, severing of muscle at stomach outlet to upper small bowel costs an estimated $940.83 on average (range: $658.58-$1,317.16), a moderate premium over Medicare's $335.56. Without insurance, the estimated cash price is $1,002.20.
How many providers perform Severing Of Muscle At Stomach Outlet To Upper Small Bowel?
Severing Of Muscle At Stomach Outlet To Upper Small Bowel is comparatively uncommon: only 54 providers nationally billed Medicare for it in 2023, serving 71 beneficiaries via 81 total services.
What is the billed-to-Medicare markup for Severing Of Muscle At Stomach Outlet To Upper Small Bowel?
Providers bill 7.4x what Medicare pays for Severing Of Muscle At Stomach Outlet To Upper Small Bowel - a higher-than-typical markup at 645% 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.