CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Hermann Area District Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $526
Cash Discount Price: $693
vs. Medicare Baseline: 0.57x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Hermann Area District Hospital is $526. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $693. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 0.57x the Medicare baseline. Located in 509 W 18Th St, Hermann, MO.

Cash / Self-Pay

$693

Average discount available for prompt cash payment at this facility.

Insurance Median

$526

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: $693 (75%)

Insurance Median: $526 (57%)

Cash: $693 (75% of Medicare)

Ins. Median: $526 (57% 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
Healthy Blue Mcaid - All Plans	$287	31%
Ambetter / Centene	$299 - $825	32%
Blue Cross Blue Shield	$310 - $531	33%
UnitedHealthcare	$310 - $492	33%
Tricare	$450 - $464	49%
Choicecare Mcr Adv- All Plans	$478 - $492	52%
American Hlth Mcr Adv- All Plans	$500 - $516	54%
Humana	$500 - $516	54%
Aetna	$510 - $1,113	55%
Wellcare Mcr Adv - All Plans	$510 - $526	55%
Care Partners Mcaid- All Plans	$562	61%
Harmony Hp Mcaid- All Plans	$659 - $680	71%
Healthcare Usa Mcaid- All Plans	$739 - $762	80%
Healthlink Hmo	$739 - $762	80%
Healthlink Ppo - All Other Plans	$853 - $879	92%
Multiplan/Phcs - All Plans	$853 - $879	92%
Coventry - All Plans	$966 - $996	104%
Comp Results - All Plans	$1,023 - $1,055	110%
Three Rivers - All Plans	$1,023 - $1,055	110%

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 $693.
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 Hermann Area District 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.