CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Adventist Health Sonora

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $234
Cash Discount Price: $80
vs. Medicare Baseline: 0.25x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Adventist Health Sonora is $234. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $80. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 0.25x the Medicare baseline. Located in 1000 Greenley Road, Sonora, CA.

Cash / Self-Pay

$80

Average discount available for prompt cash payment at this facility.

Insurance Median

$234

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: $80 (9%)

Insurance Median: $234 (25%)

Cash: $80 (9% of Medicare)

Ins. Median: $234 (25% 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.

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
Blue Shield Mcare	$124	13%
Central Ca Alliance Mcr Adv Profee Only	$124	13%
Healthnet Mcr Adv	$124	13%
Tricare	$124	13%
UnitedHealthcare	$124 - $403	13%
Ah Employee Health Plan - All Plans	$137	15%
Cigna	$153	17%
Greatwest Oa/Pos/Hmo	$162	17%
Greatwest Ppo - All Other Plans	$162	17%
Western Growers/Pinnacle - All Plans	$173	19%
Healthnet - All Other Plans	$181	20%
Bc Mcal	$234	25%
Celtic Ca Hlth Well Mcal - All Plans	$234	25%
Central Ca Alliance Mcal	$234	25%
Healthnet Mcal	$234	25%
Medi-Cal	$234	25%
Aetna	$283	31%
Central Ca Alliance Ccs Mcal	$351	38%
Central Ca Alliance Comm Profee Only-All Other Pla	$351	38%
Beech Street- All Plans	$421	45%
Trpn - Three Rivers Ppo - All Plans	$421	45%
Bc Mcs	$445	48%
Bc Non-Mcs - All Other Plans	$445	48%
Central Ca Alliance Chdp Mcal	$468	51%
Blue Shield Epn	$621	67%
Blue Shield - All Other Plans	$656	71%

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 $80.
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 Adventist Health Sonora 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.