CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Providence St. Joseph Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $3,940
Cash Discount Price: $1,223
vs. Medicare Baseline: 4.25x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Providence St. Joseph Hospital is $3,940. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $1,223. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 4.25x the Medicare baseline. Located in 1100 West Stewart Dr, Orange, CA.

Cash / Self-Pay

$1,223

Average discount available for prompt cash payment at this facility.

Insurance Median

$3,940

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$926.63

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $926.63 (100%)

Cash / Self-Pay: $1,223 (132%)

Insurance Median: $3,940 (425%)

Cash: $1,223 (132% of Medicare)

Ins. Median: $3,940 (425% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $926.63 as the cost baseline. Rates below the baseline represent excellent value. In-network commercial rates commonly hover around 150% - 250% of Medicare, while rates exceeding 300% are elevated. Hover over the green and blue markers to view detailed calculations.

Elevated Commercial Rate Alert (Value-Gap)

The negotiated rate at this facility is 425% of the Medicare baseline (a markup of 325%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.

Consult Patient Advocate

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

Input your details and click calculate to compare out-of-pocket costs.

Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Providence	$992	107%
Aetna	$1,167 - $4,035	126%
Blue Cross Blue Shield	$1,222 - $13,747	132%
Healthnet	$2,158 - $3,462	233%
UnitedHealthcare	$3,845 - $4,218	415%
Blue Shield	$6,652 - $9,162	718%

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $1,223.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 43239.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Providence St. Joseph Hospital is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 43239.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.