CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: St Mary Medical Center

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $2,200
Cash Discount Price: $3,938
vs. Medicare Baseline: 2.37x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at St Mary Medical Center is $2,200. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $3,938. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 2.37x the Medicare baseline. Located in Langhorne-Newtown Rd, Langhorne, PA.

Cash / Self-Pay

$3,938

Average discount available for prompt cash payment at this facility.

Insurance Median

$2,200

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: $3,938 (425%)

Insurance Median: $2,200 (237%)

Cash: $3,938 (425% of Medicare)

Ins. Median: $2,200 (237% 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 237% of the Medicare baseline (a markup of 137%). 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
Medicaid / KanCare	$51 - $2,581	6%
Blue Cross Blue Shield	$978 - $4,967	106%
Cigna	$987 - $4,432	107%
Align Senior Care	$997 - $2,110	108%
Medicare (plans)	$1,002 - $3,724	108%
Aetna	$1,035 - $2,190	112%
Health America Advantra	$1,173 - $2,482	127%
Ambetter / Centene	$1,745 - $3,693	188%
Oscar	$1,760 - $3,724	190%
Prime Healthcare	$1,760 - $3,724	190%
Jefferson Health Plan Commercial	$1,780 - $3,765	192%
Homestead Health Plans Woods Center	$1,907 - $4,034	206%
UnitedHealthcare	$1,958 - $3,742	211%
Group Pension Administrators	$2,200 - $4,655	237%
Reedman Toll	$2,200 - $4,655	237%
Amerihealth	$2,213	239%
Blue Shield - Ca	$2,213	239%
Blue Shield - Id (Regence)	$2,213	239%
Blue Shield - Ny Highmark Western	$2,213	239%
Blue Shield - Wa (Regence)	$2,213	239%
Keystone First	$2,581	279%
Keystone First Chip	$2,581	279%
Blue Shield - Pa (Highmark)	$2,644 - $5,594	285%
Geha	$3,742	404%
Upmc Health Plan	$4,432	478%
Webtpa	$4,432	478%

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 $3,938.
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 Mary 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.