Gastroenterology reimbursement rates by service line
Compare national gastroenterology reimbursement benchmarks calculated from price transparency data. Reference benchmarks cover 43239, 45378 and 45385 across Aetna, Anthem, Cigna and United. Reporting periods: Jun–Jul 2026.
Rate Explorer
Compare national gastroenterology rates by payer
Start with three common endoscopy services, then compare payer ranges and named billing entities in the state relevant to your question.
Aetna state variation for 45378
National 45378 rate distribution
Each marker shows the national median published rate across billing entities for that payer.
National 45378 rates by payer
| Payer | Rate period | Provider entities | P25 | Median | P75 | P90 | Average |
|---|---|---|---|---|---|---|---|
| Aetna | Jun–Jul 2026 | 24,815 | $380.90 | $440.29 | |||
| Cigna | Jun–Jul 2026 | 25,404 | $436.34 | $514.96 | |||
| United | Jun–Jul 2026 | 26,121 | $611.92 | $682.53 | |||
| Anthem | Jun–Jul 2026 | 22,825 | $460.85 | $619.44 |
- Source
- Negotiated or fee-schedule amounts published directly by payers in their machine-readable files.
- Rate shown
- Published commercial rate for diagnostic colonoscopy (45378).
- Method
- Eligible rates are grouped by payer and billing entity so the benchmarks use a consistent service and billing basis.
The state map uses one consistent Aetna reference series; it does not average already-aggregated payer values. The service-line table keeps unlike codes, settings, and billing units in separate comparisons.
Confirm coverage for your codes, payers and markets.
How do specific gastroenterology providers compare?
Compare named provider rates with the selected payer's median and percentile distribution.
National: Gastroenterology provider rates by payer (CPT 45378)
| Provider entity | State | Size | $ per service | Gap to median | Position in Aetna range |
|---|---|---|---|---|---|
| IRONWOOD GASTROENTEROLOGY PLLCNPI 1003031931 · Tax ID 208692925 | AZ | 3 | $239.35 | -$141.55 | Below P25 |
| HORIZONS DIAGNOSTICS LLCNPI 1437150455 · Tax ID 582470331 | GA | 29 | $273.73 | -$107.17 | Below P25 |
| MUKUL KHANDELWAL PANPI 1316928849 · Tax ID 522109222 | MD | 20 | $302.26 | -$78.64 | Below P25 |
| MEMORIAL HOSPITALNPI 1073613808 · Tax ID 381358208 | MI | 503 | $329.07 | -$51.83 | P25 to median |
| MERCY CLINIC FORT SMITH COMMUNITIESNPI 1013170596 · Tax ID 261318597 | AR | 953 | Median to P75 | ||
| MEMORIAL CLINICAL NUTRITION GROUPNPI 1821152943 · Tax ID 133278576 | PA | 10 | Above P75 |
Choose one state to replace the mixed-state examples with payer-specific provider rates for available preview codes.
No trial or data preparation required.Which providers have the highest claim volume in the gastroenterology market?
Provider organizations with the highest combined 2024 Medicare and Medicaid claim volume in the gastroenterology market.
- 1ILIllinois Gastroenterology Group LLCNPI 1316277817Medicare 37,388Medicaid 86,464123,852 total
- 2OHDayton Gastroenterology INC.NPI 1134345705Medicare 49,660Medicaid 2,97052,630 total
- 3FLGastro Health LLCNPI 1487767133Medicare 49,987Medicaid 29450,281 total
- 4MULTITexas Digestive Disease ConsultantsNPI 1689650475Medicare 39,746Medicaid 2,68442,430 total
- 5PARegional Gastroenterology Associates Of Lancaster LtdNPI 1154422806Medicare 19,227Medicaid 22,32241,549 total
- 6ALGut PCNPI 1073566006Medicare 35,176Medicaid 3,19538,371 total
- 7ILGi Partners Of Illinois LLCNPI 1548613995Medicare 4,332Medicaid 32,03536,367 total
- 8OHOhio Gastroenterology Group INCNPI 1124197637Medicare 32,840Medicaid 1,93734,777 total
- 9WAWashington Gastroenterology PLLCNPI 1306364401Medicare 33,917Medicaid 57134,488 total
- 10TNGastroenterology Center Of The Midsouth P.C. Dba Gastro OneNPI 1417932492Medicare 28,902Medicaid 2,06230,964 total
- 11OHDigestive Specialists INCNPI 1770556532Medicare 26,758Medicaid 1,43128,189 total
- 12FLGastromed LLCNPI 1538491063Medicare 24,746Medicaid 68225,428 total
- 13NCDigestive Health Partners PANPI 1326037680Medicare 23,849Medicaid 1,26225,111 total
- 14AZArizona Digestive Health PCNPI 1992981583Medicare 21,943Medicaid 2,58224,525 total
- 15MITroy Gastroenterology PCNPI 1134180318Medicare 22,539Medicaid 62123,160 total
- 16TXGastroenterology Consultants of South Texas P.A.NPI 1821127002Medicare 20,804Medicaid 18920,993 total
- 17OHGcga Physicians INC.NPI 1790851095Medicare 13,194Medicaid 6,80019,994 total
- 18NCCarolina Digestive Health Associates PANPI 1124052444Medicare 18,681Medicaid 1,30319,984 total
- 19FLWest Central GastroenterologyNPI 1144454703Medicare 17,703Medicaid 87218,575 total
- 20CORocky Mountain Gastroenterology Associates PLLCNPI 1669414272Medicare 7,932Medicaid 9,30117,233 total
How reimbursement changes across gastroenterology services
Keep procedures, visits, pathology, laboratory services, and drugs in their own payment units so payer rates stay comparable.
| Service line / billing code | Aetna | Cigna | United | Anthem |
|---|---|---|---|---|
$ per service · 1 code | ||||
43239Upper GI endoscopy with biopsy | $414.70 | $489.05 | $736.27 | $655.76 |
$ per service · 3 codes | ||||
45378Diagnostic colonoscopy | $440.29 | $514.96 | $682.53 | $619.44 |
45380Colonoscopy with biopsy | $525.94 | $625.50 | $864.63 | $719.01 |
45385Colonoscopy with lesion removal by snare | $589.83 | $701.56 | $917.03 | $832.98 |
$ per visit · 8 codes | ||||
99203New patient office visit, level 3 | $119.65 | $154.18 | $177.47 | $174.32 |
99204New patient office visit, level 4 | $185.02 | $238.76 | $268.94 | $267.70 |
99213Established patient office visit, level 3 | $87.50 | $112.93 | $125.78 | $124.48 |
99214Established patient office visit, level 4 | $127.70 | $163.95 | $181.93 | $177.22 |
99215Established patient office visit, level 5 | $179.29 | $233.90 | $247.43 | $252.70 |
99223Initial hospital care, high level | $218.82 | $298.23 | $318.54 | $335.63 |
99232Subsequent hospital care, moderate level | $90.98 | $117.65 | $119.74 | $128.64 |
99233Subsequent hospital care, high level | $126.08 | $171.94 | $173.99 | $186.41 |
$ per service · 6 codes | ||||
36415Collection of venous blood by venipuncture | $6.68 | $6.31 | $3.64 | $6.34 |
80053Comprehensive metabolic panel | $13.62 | $24.45 | $9.33 | $17.84 |
83036Hemoglobin A1c | $12.68 | $22.29 | $8.66 | $17.19 |
85025Complete blood count with differential | $10.16 | $18.38 | $6.94 | $13.50 |
88305Surgical pathology, gross and microscopic examination | $94.26 | $86.49 | $87.58 | $154.13 |
88313Special stains, group 2 | $94.82 | $85.10 | $88.20 | $132.59 |
$ per HCPCS unit · 2 codes | ||||
J1745Infliximab | $44.02 | $35.24 | $39.51 | $49.87 |
J3380Vedolizumab | $26.04 | $22.33 | $24.97 | $31.05 |
Tell us the services, payers, states, and networks you need. We'll confirm available coverage and scope the comparison on a 20-minute call.
Book a 20-min scoping call No trial or data preparation required.How to read these gastroenterology rates
Benchmarks calculated by PayerPrice from health plan price transparency files. CMS price transparency requirements.
- Published rates, not paymentsThese figures summarize negotiated rates reported by health plans. They are not claim payments, patient prices or a provider's verified contract.
- Average vs. medianThe average combines eligible billing-entity rates; the median is the middle rate. A large gap between them can signal that high or low rates are pulling the average.
- What a provider row meansA billing entity may be a clinician, practice, facility or health system. A named row does not always represent one individual provider.
- Compare like for likeMatch the code, billing component, setting, payment unit, network and reporting period. Facility, drug and other service payments may be separate.
Calculation details and specialty-specific notes
We start with negotiated or fee-schedule rates published in payer machine-readable files and included in the underlying professional gastroenterology report. For each selected billing code, eligible records are grouped by payer and summarized as averages and percentile distributions.
- Rate source
- The displayed amount is a negotiated or fee-schedule amount published in a payer machine-readable file, not a paid claim, billed charge, or utilization-based estimate.
- Rate calculation
- National values summarize eligible published records across available states. State views use records associated with the selected state. Averages are not weighted by procedure volume. The calculation targets the lowest and highest 2% of entity rates for removal, rounded down to whole entities. Tied boundary values stay together, so fewer rates may be removed. A payer, code and geography cohort is published only when at least 10 billing entities remain after trimming. A missing benchmark does not mean the rate is zero.
- Provider entity
- Named examples use payer-file NPI and TIN records. An entity may be a clinician, group, health system, or other billing organization; the listed state may not be its headquarters. Each NPI and TIN combination contributes one representative rate: its most frequent normalized value. When multiple values are equally frequent, those values are averaged.
- Comparable rates
- Match the exact procedure, billing component, modifier, site of service, payment unit, payer product, and network. Facility, anesthesia, pathology, drug, and administration payments may be separate. Benchmarks keep the payer, service code, geography, reporting period and billing unit separate. Different services or payment units are not blended into one rate.
Compare Gastroenterology rates in your market
Tell us the services, payers and locations you need. We'll confirm coverage and scope the comparison.
- Define the scopeChoose the codes, payers, networks and providers.
- Match the billing detailsWe align services, settings and payment units.
- Compare the ratesReview payer and provider rates for your selected market.
We'll explain what's available, flag gaps and help define the comparison.
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Explore gastroenterology rates by state
Choose a state to compare payer reference averages for common services.
How to interpret gastroenterology rates
How to interpret the selected market and payer-published rates.
Should ASC and hospital outpatient gastroenterology rates be compared?
Only when the billing component is the same. This page is configured for professional gastroenterology rates; ASC and hospital outpatient facility payments should be evaluated separately.
How should diagnostic, biopsy, and lesion-removal colonoscopy rates be benchmarked?
Compare each procedure using its exact billing code. Diagnostic colonoscopy, biopsy, and lesion removal represent different services and should not be combined into one rate.
Are pathology, anesthesia, drug, and administration payments included?
Not in the selected endoscopy rate. These services may appear as separate billing codes and should be evaluated independently when they are relevant to the comparison.
Which billing details can change the comparison?
Confirm the billing code, modifier, site of service, professional or facility context, payment unit, payer product, and network before treating two rates as comparable.
How are named provider examples selected?
Provider examples are sampled across each payer's published rate range. The national overview includes public provider samples; state provider-level comparisons require a free state preview.