CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Lutheran Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $1,583
Cash Discount Price: $2,426
vs. Medicare Baseline: 1.71x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Lutheran Hospital is $1,583. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $2,426. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 1.71x the Medicare baseline. Located in 1730 West 25Th Street, Cleveland, OH.

Cash / Self-Pay

$2,426

Average discount available for prompt cash payment at this facility.

Insurance Median

$1,583

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: $2,426 (262%)

Insurance Median: $1,583 (171%)

Cash: $2,426 (262% of Medicare)

Ins. Median: $1,583 (171% 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
UnitedHealthcare	$604 - $2,314	65%
Paramount	$654	71%
Blue Cross Blue Shield	$667 - $2,924	72%
Buckeye	$667	72%
Molina	$667	72%
United Bh	$674	73%
Caresource	$680	73%
United	$680 - $4,338	73%
Amerihealth	$699	75%
Aetna	$869 - $3,732	94%
Devoted Health	$869	94%
Humana	$869 - $3,172	94%
Mmo	$869 - $2,345	94%
Summacare	$869 - $1,508	94%
The Health Plan	$869 - $2,239	94%
Upmc	$869 - $2,239	94%
Valor	$869	94%
Cigna	$895 - $2,986	97%
Communicare	$913	99%
Perennial Health	$939	101%
Pphp	$956	103%
Zing Health	$956	103%
Oscar	$1,124 - $1,435	121%
Cc Ehp	$1,489 - $1,511	161%
Aultcare	$1,605	173%
Amish Community Aid Plan	$1,679 - $1,866	181%
Ohcp	$1,814	196%
Omas	$1,866	201%
Ohio Healthy	$2,015	217%
Healthsmart	$2,053	222%
Php	$2,239	242%
Phphi	$2,239	242%
Gms	$2,612	282%
Medical Benefit Corp	$2,612	282%
Quality Care Partners	$2,612	282%
Consociate Health	$2,799	302%
Frontpath	$3,359	362%
Managed Care Services	$3,359	362%
Multiplan	$3,359	362%
Tertiary Care Network	$3,359	362%
Three Rivers	$3,359	362%

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 $2,426.
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 Lutheran 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.