CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: St Clair Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $1,977
Cash Discount Price: $705
vs. Medicare Baseline: 2.13x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at St Clair Hospital is $1,977. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $705. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 2.13x the Medicare baseline. Located in 1000 Bower Hill Road, Pittsburgh, PA.

Cash / Self-Pay

$705

Average discount available for prompt cash payment at this facility.

Insurance Median

$1,977

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: $705 (76%)

Insurance Median: $1,977 (213%)

Cash: $705 (76% of Medicare)

Ins. Median: $1,977 (213% 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 213% of the Medicare baseline (a markup of 113%). 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
Pa Health And Wellness	$149 - $919	16%
UnitedHealthcare	$156 - $2,899	17%
Geisinger	$157 - $910	17%
Health Partners	$157 - $928	17%
Aetna	$171 - $2,368	18%
Amerihealth	$171 - $883	18%
Highmark	$171 - $1,977	18%
Upmc	$309 - $2,974	33%
Humana	$883	95%
Cigna	$919 - $2,027	99%
The Health Plan	$928 - $2,120	100%
Lantern	$1,899	205%

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 $705.
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 Clair 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.