CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Adena Pike Medical Center

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $4,139
Cash Discount Price: $2,746
vs. Medicare Baseline: 4.47x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Adena Pike Medical Center is $4,139. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $2,746. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 4.47x the Medicare baseline. Located in 100 Dawn Lane, Waverly, OH.

Cash / Self-Pay

$2,746

Average discount available for prompt cash payment at this facility.

Insurance Median

$4,139

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: $2,746 (296%)

Insurance Median: $4,139 (447%)

Cash: $2,746 (296% of Medicare)

Ins. Median: $4,139 (447% 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.

Elevated Commercial Rate Alert (Value-Gap)

The negotiated rate at this facility is 447% of the Medicare baseline (a markup of 347%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.

Consult Patient Advocate

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
Aetna	$1,318 - $4,470	142%
Blue Cross Blue Shield	$1,318 - $4,740	142%
Buckeye Community Health Plan	$1,318	142%
Humana	$1,318 - $5,217	142%
Medical Mutual Of Ohio	$1,318 - $3,490	142%
Medigold	$1,318	142%
Molina	$1,318	142%
Care Source	$1,344	145%
Gateway Health	$1,812	196%
Molina Marketplace	$2,162	233%
Care Source Just4Me	$2,373	256%
UnitedHealthcare	$2,665	288%
Sidecar Health	$3,625	391%
Ohio Ppo Connect	$3,844	415%
The Health Plan	$3,844	415%
Cigna	$3,976	429%
Medical Mutual Of Ohio Supermed	$4,139	447%
First Health	$4,306	465%
Ohio Health Choice	$4,372	472%
Integrated Health Plan	$5,162	557%
Healthsmart	$5,217	563%
Multiplan/Private Healthcare Systems	$5,217	563%
Three Rivers Network	$5,217	563%

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 $2,746.
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 Adena Pike 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.