CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: St Claire Regional Medical Center

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $499
Cash Discount Price: $1,187
vs. Medicare Baseline: 0.54x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at St Claire Regional Medical Center is $499. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $1,187. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 0.54x the Medicare baseline. Located in 222 Medical Circle, Morehead, KY.

Cash / Self-Pay

$1,187

Average discount available for prompt cash payment at this facility.

Insurance Median

$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: $1,187 (128%)

Insurance Median: $499 (54%)

Cash: $1,187 (128% of Medicare)

Ins. Median: $499 (54% 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 Cross Blue Shield	$119 - $1,921	13%
Caresource Mcr Adv	$119 - $940	13%
Humana	$119 - $1,867	13%
Healthlink - All Plans	$126 - $1,849	14%
Wellcare Comm - All Other Plans	$148 - $2,267	16%
Ky Health Co-Op - All Plans	$154 - $3,467	17%
Caresource Just4Me - All Other Plans	$166 - $1,222	18%
Aetna	$179 - $499	19%
Beacon Bh - All Plans	$188	20%
Medicaid / KanCare	$499 - $749	54%
Wellcare Mcaid	$509 - $613	55%

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 $1,187.
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 St Claire Regional Medical Center 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.