CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: St Mary's General Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $1,715
Cash Discount Price: $1,072
vs. Medicare Baseline: 1.85x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at St Mary's General Hospital is $1,715. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $1,072. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 1.85x the Medicare baseline. Located in 350 Boulevard, Passaic, NJ.

Cash / Self-Pay

$1,072

Average discount available for prompt cash payment at this facility.

Insurance Median

$1,715

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: $1,072 (116%)

Insurance Median: $1,715 (185%)

Cash: $1,072 (116% of Medicare)

Ins. Median: $1,715 (185% 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
Humana	$858	93%
Aetna	$1,072 - $2,273	116%
Wellcare	$1,072 - $1,448	116%
Horizon	$1,072 - $1,901	116%
UnitedHealthcare	$1,072 - $4,153	116%
Clover Health	$1,072	116%
Medicare (plans)	$1,072	116%
Tricare	$1,072	116%
Amerihealth	$1,072	116%
Wellpoint Amerigroup	$1,072	116%
Ally-Align (Fka Spartan Plan Nj, Inc.)	$1,126	122%
Employer Direct Healthcare	$1,501	162%
Cigna	$1,576	170%
Wellchoice	$1,715 - $1,978	185%
Fairprice Healthcare Holdings	$1,716	185%
Coventry	$2,144	231%

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 $1,072.
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 Mary's General 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.