CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: St James Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $306
Cash Discount Price: Unavailable
vs. Medicare Baseline: 0.33x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at St James Hospital is $306. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is unavailable. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 0.33x the Medicare baseline. Located in 411 Canisteo Street, Hornell, NY.

Cash / Self-Pay

Unavailable

Average discount available for prompt cash payment at this facility.

Insurance Median

$306

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%)

Insurance Median: $306 (33%)

Ins. Median: $306 (33% 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	$84 - $2,711	9%
Medicaid / KanCare	$86 - $355	9%
Fidelis 5155	$100 - $320	11%
Aetna	$112 - $1,213	12%
Excellus 2201	$112 - $708	12%
Medicare (plans)	$112 - $1,334	12%
UnitedHealthcare	$118 - $2,264	13%
Mvp 2900	$120 - $2,632	13%
Cigna	$166 - $2,727	18%
Capital District Physicians Health Plan (Cdphp) 5149	$335 - $926	36%
Humana	$1,213	131%
Empire Plan 5179	$2,558	276%

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 $X.
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 James 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.