CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: HSHS St Elizabeth's Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $2,499
Cash Discount Price: $2,070
vs. Medicare Baseline: 2.70x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at HSHS St Elizabeth's Hospital is $2,499. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $2,070. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 2.70x the Medicare baseline. Located in One St Elizabeth Boulevard, O Fallon, IL.

Cash / Self-Pay

$2,070

Average discount available for prompt cash payment at this facility.

Insurance Median

$2,499

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: $2,070 (223%)

Insurance Median: $2,499 (270%)

Cash: $2,070 (223% of Medicare)

Ins. Median: $2,499 (270% 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 270% of the Medicare baseline (a markup of 170%). 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
Amish Community	$787 - $823	85%
Molina Healthcare	$878 - $1,096	95%
Meridian Health Plan	$920	99%
Aetna	$1,047 - $2,070	113%
Blue Cross Blue Shield	$1,047 - $2,940	113%
Clear Spring Health Of Illinois	$1,047	113%
Health Alliance Medical Plans	$1,047 - $2,499	113%
Health Partners	$1,047	113%
Humana	$1,047	113%
Sae Hospice	$1,047	113%
UnitedHealthcare	$1,047 - $2,940	113%
Wellfirst	$1,810 - $1,893	195%
Celtic Insurance Company	$2,091	226%
First Health	$2,091 - $2,187	226%
Cigna	$2,221 - $2,940	240%
Healthlink	$2,235 - $2,940	241%
Caterpillar, Inc.	$2,257 - $2,361	244%
Naphcare	$2,268	245%
Consociate Group	$2,474 - $2,587	267%
Hopetrust	$2,513	271%
Choicecare	$2,530 - $2,646	273%
Healthcare Finest Network (Hfn)	$2,530 - $2,646	273%
Multiplan/Phcs	$2,530 - $2,646	273%
Provider Network Of America	$2,530 - $2,646	273%
Claim Doc	$2,617	282%
City Of Springfield	$2,811 - $2,940	303%
Current Health Solutions	$2,811 - $2,940	303%
Healthscope	$2,811 - $2,940	303%
Illinois Breast And Cervical Cancer Program	$2,811 - $2,940	303%
Interplan	$2,811 - $2,940	303%
Live360	$2,811 - $2,940	303%
Wexford	$2,811 - $2,940	303%

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 $2,070.
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 HSHS St Elizabeth's 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.