Upper Endoscopy (EGD) price: Medicare anchor and facility lever
Anchor for Upper Endoscopy (EGD) - CPT 43235
$114.85
Nonfacility PFS $319.52; facility professional PFS $114.85.
Upper endoscopy, or EGD, follows the same layered billing as colonoscopy but with its own codes. CPT 43235 is the diagnostic procedure. If a biopsy is taken it becomes 43239, which raises the professional anchor and adds a pathology bill. Pricing EGD well means getting a written number for both codes before the day.
CPT code
43235
Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
CPT 43235 is diagnostic EGD. With biopsy is 43239. Confirm the expected code before comparing quotes, because a biopsy changes both the procedure code and the pathology bill.
The codes this visit can be billed under
| CPT | PFS office or global | PFS facility (professional) | Global period | Hospital single-service APC | Minimum Medicare copay at hospital |
|---|---|---|---|---|---|
| 43235 (this page) | $319.52 | $114.85 | 0 days | $926.63 (APC 5301) | $185.33 |
| 43239 | $413.41 | $128.48 | 0 days | $926.63 (APC 5301) | $185.33 |
| 88305 | $69.02 | $69.02 | not a surgical global | $53.24 (APC 5671) | $10.65 |
In a hospital outpatient department, 43235 and 43239 map to the same CY2026 APC 5301 at $926.63, with a minimum unadjusted copayment of $185.33. So the hospital facility line does not change when a biopsy is added; the professional anchor does, from $114.85 to $128.48 in a facility, and a pathology charge appears.
In an office endoscopy suite, the nonfacility anchor of $319.52 carries the practice overhead, and there is no separate facility bill. That is the one setting where the professional figure on the quote is meant to cover the room as well.
For a Medicare patient, the hospital line for 43235 carries a minimum unadjusted copayment of $185.33, and the endoscopist's coinsurance is figured on the facility professional anchor of $114.85. The CMS fee schedule lists a 0-day global period for 43235, so a separate follow-up visit after the procedure is billed on its own rather than being included in the procedure fee.
Inside and outside the 43235 anchor
Covered by the anchor
- Endoscopist professional fee for the diagnostic procedure (PFS anchor below)
- Use of the endoscopy suite and standard recovery monitoring in the facility payment
Billed outside it
- Anesthesia or sedation billed separately
- Pathology when a biopsy is taken (for example 88305)
- The pre-procedure visit and follow-up visit when billed separately
Why prices vary for CPT 43235
Like colonoscopy, EGD pricing splits into professional, facility, anesthesia, and pathology layers. The PFS professional anchor is lower in a facility setting than in an office because the facility payment carries the overhead. Hospital OPPS facility payment is higher than the ASC facility payment for the same endoscopy family, which is the main lever a patient can shop on when the clinician practices in more than one setting.
Ask for the setting (hospital vs ASC vs office), the anesthesia plan, and whether a biopsy is expected. Price each layer separately, then add them.
Questions specific to Upper endoscopy / EGD
- If a biopsy is taken, will the code change to 43239, and what is the written price?
- Is the facility fee in the quote, and is it a hospital or surgery-center fee?
- Who administers sedation, and is that a separate bill?
- Which lab examines any tissue, and does it bill you directly?
Upper Endoscopy (EGD): billing questions
Does adding a biopsy change the hospital's facility charge for EGD?
Under the CY2026 OPPS addenda, 43235 and 43239 both map to APC 5301, so the Medicare facility anchor is the same. The professional anchor rises with the biopsy code, and tissue examination brings a separate pathology charge.
Why is the office anchor for EGD higher than the facility anchor?
The nonfacility amount includes practice expense for the room, staff and equipment. The facility amount is lower because the hospital or surgery center bills its own fee for those costs.
What is the pathology bill after an EGD?
When tissue is sent out, a pathologist examines it and bills separately, commonly under CPT 88305. Its CY2026 Michigan Locality 01 global anchor is shown in the code table on this page.
Is a follow-up visit after an EGD included in the procedure price?
Not under the Medicare fee schedule. CPT 43235 has a 0-day global period in the CY2026 file, so a later office visit is a separate service with its own charge. Ask the practice how it bills follow-up.