CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Kenmore Mercy Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $131
Cash Discount Price: $751
vs. Medicare Baseline: 0.14x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Kenmore Mercy Hospital is $131. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $751. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 0.14x the Medicare baseline. Located in 2950 Elmwood Avenue, Kenmore, NY.

Cash / Self-Pay

$751

Average discount available for prompt cash payment at this facility.

Insurance Median

$131

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: $751 (81%)

Insurance Median: $131 (14%)

Cash: $751 (81% of Medicare)

Ins. Median: $131 (14% 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	$92 - $152	10%
Excellus Rochester McD [350117]	$101	11%
Blue Cross Blue Shield	$101 - $192	11%
Tuscarora Nation [550120]	$101	11%
Vna Option Mltc [350110]	$101	11%
Independent Health Essential [100166]	$101	11%
Medicaid / KanCare	$101 - $131	11%
Crime Victims [100176]	$101	11%
Amerigroup [350102]	$101	11%
Univera Healthcare Essential [100170]	$113	12%
Univera Healthcare [100169]	$113 - $166	12%
Beacon Essential [350122]	$118 - $158	13%
VA Veterans Affairs [700001]	$118	13%
Medicare (plans)	$129 - $358	14%
Hospice [550001]	$131	14%
Tricare	$131	14%
Champ VA [700002]	$131	14%
Cigna	$131 - $191	14%
Catholic Health Life Pace [400005]	$131	14%
Seneca Nation [450119]	$131	14%
Covid19 Hrsa [45013]	$131	14%
Fallon Health [450115]	$131	14%
Humana	$138	15%
Wellcare Fidelis Dual [450451]	$138	15%
Fidelis Dual Advantage [450120]	$138	15%
Aetna	$138	15%
Wellcare [450129]	$145	16%
Ghi [100153]	$145	16%
Fidelis Essential [100163]	$145	16%
Beacon Health Options [100023]	$158	17%
Fidelis Exchange [100164]	$158	17%
Mvp Healthcare [100168]	$172	19%
Independent Health [100165]	$204	22%
Iha First Choice [800001]	$204	22%
Molina Essential [100167]	$227	24%
UPMC Health Plan [100181]	$237	26%
No Fault [114001]	$604	65%
Federal Workers Compensation [500100]	$604	65%

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 $751.
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 Kenmore Mercy 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.