CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: UPMC St Margaret

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $1,989
Cash Discount Price: $4,158
vs. Medicare Baseline: 2.15x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at UPMC St Margaret is $1,989. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $4,158. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 2.15x the Medicare baseline. Located in 815 Freeport Road, Pittsburgh, PA.

Cash / Self-Pay

$4,158

Average discount available for prompt cash payment at this facility.

Insurance Median

$1,989

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: $4,158 (449%)

Insurance Median: $1,989 (215%)

Cash: $4,158 (449% of Medicare)

Ins. Median: $1,989 (215% 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 215% of the Medicare baseline (a markup of 115%). 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
UnitedHealthcare	$163	18%
Upmc Health Plan	$163 - $1,040	18%
Highmark Wholecare (Prev Gateway)	$220 - $965	24%
Amerihealth Caritas	$232	25%
Pa Health & Wellness	$253 - $965	27%
Blue Cross Blue Shield	$737 - $4,394	80%
Upmc Work Partners	$757	82%
Aetna	$939 - $2,772	101%
Cigna	$1,940 - $2,772	209%
Coventry/First Health	$4,851	524%
Private Health Care Systems	$5,544	598%
Selectcare	$5,544	598%
Humana	$5,890	636%

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 $4,158.
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 UPMC St Margaret 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.