This is the fourth exhibit in the Line Items series. It annotates a diagnostic colonoscopy, one of the most common and most price-variable procedures in outpatient medicine. The same colonoscopy can cost $1,250 at a freestanding ambulatory surgery center or $8,500 at a hospital outpatient department. That gap is not driven by quality. It is driven by where you have it done.
The bill, annotated
The table below represents a composite diagnostic colonoscopy with one polyp removal (polypectomy) at a hospital outpatient department. Figures are based on publicly reported data, MDsave marketplace listings, and CMS facility fee schedules.
Diagnostic Colonoscopy with Polypectomy - Hospital Outpatient
| Line Item | Chargemaster | Cash-Pay Range | Note |
|---|---|---|---|
| Facility fee (endoscopy suite) | $4,200 | $800 - $2,200 | This is the line that varies the most |
| Gastroenterologist professional fee | $1,400 | $400 - $800 | Separate bill from the GI practice |
| Anesthesia (MAC/propofol, ~30 min) | $1,800 | $350 - $800 | Third separate bill, anesthesia group |
| Pathology (polyp biopsy) | $650 | $100 - $350 | Fourth bill, arrives 2-4 weeks later |
| Pre-procedure labs | $380 | $30 - $90 | CBC, metabolic panel if ordered |
| Recovery room (1-2 hrs) | $900 | $200 - $500 | Post-anesthesia monitoring |
| Supplies (scope, biopsy forceps) | $450 | $100 - $250 | Often bundled into facility fee at ASCs |
| Total | $9,780 | $1,980 - $4,990 | ASC all-inclusive: ~$1,250 - $2,000 |
↑ Four separate bills for one procedure. The facility, the gastroenterologist, the anesthesiologist, and the pathologist all bill independently. The patient receives one colonoscopy but four pieces of mail.
The facility fee gap
The facility fee is where the self-pay patient either saves or loses thousands of dollars. CMS data consistently shows that freestanding ambulatory surgery centers charge 60% to 80% less than hospital outpatient departments for the identical procedure performed by the same physician. This is not because the ASC cuts corners. It is because the hospital's facility fee includes overhead for services the colonoscopy patient never uses: the emergency department, the ICU, the inpatient wards, and the administrative infrastructure that supports them.
Same Colonoscopy, Different Facility: Total Cash-Pay Cost
Diagnostic colonoscopy with polypectomy. Sources: MDsave, ColonoscopyAssist, CMS OPPS payment data. Figures exclude pathology.
Screening vs diagnostic: a billing trap
Under the ACA, a screening colonoscopy for patients at average risk over age 45 is covered at no cost-sharing for insured patients. But if the gastroenterologist finds and removes a polyp during a screening colonoscopy, many insurers reclassify the procedure as diagnostic. This reclassification can shift the entire cost to the patient's deductible.
For self-pay patients, this distinction matters less in terms of insurance but more in terms of how the facility codes the procedure. A diagnostic colonoscopy (CPT 45378 with biopsy codes) is billed differently than a screening (CPT 45378 alone). Ask the facility which code they will use and whether the cash-pay price changes if a polyp is found and removed.
The prep is not on the bill but it is a cost. Prescription bowel prep solutions like MiraLAX/Gatorade combinations run $5 to $20 out of pocket. Prescription-only preps like SUTAB or Suprep run $30 to $80 with a GoodRx coupon. The prep is prescribed before the procedure and filled at a pharmacy, so it never appears on the facility bill.
Related on this site
Facility fee vs professional fee explains why you get two or more bills for a single procedure.
Exhibit B: Annotated outpatient surgery bill covers a similar outpatient procedure structure.
Elsewhere in the network
Margin Notes on surgeryquotes.com breaks down how surgery quotes are structured, including how facility and professional fees appear in international quotes.