What Insurers Pay for Upper Endoscopy (CPT 43239): 2026 Benchmarks

Part of our payer reimbursement benchmarks series — 17 payers cover 43239, with a national median of $835 and a 10.1× spread between the highest- and lowest-paying payers.

Official CMS descriptor: Egd biopsy single/multiple

MRF vintage2026-Q2

Rates analyzed752

Generated2026-06-12

Billing classInstitutional (Facility)

National benchmarks

Facility fee · national median$835all payers

IQR$777–$87225th–75th pct

Payer Spread10.1×top ÷ bottom payer

State Spread5.7×top ÷ bottom state

Rates Analyzed752from TiC filings

What this number is — and isn’t

This is the facility fee— what the insurer has contracted to pay the hospital or surgery center for this specific billing code, as published in the insurer’s Transparency in Coverage filing. It covers the technical or facility component of the procedure only. Most care episodes generate additional bills: a separate physician fee (billed under the same CPT as a professional claim), anesthesia, and follow-up care — so an all-in episode total is typically several times this line item. This number is not a patient cost estimate; what you owe depends on your deductible, coinsurance, and the other codes billed.

By payer

Negotiated medians by payer

Payer-level negotiated medians for CPT 43239
Payer	Median rate	States covered
Blue Cross Blue Shield (HCSC)	$3,238	4
Aetna	$2,180	56
CareFirst BlueCross BlueShield	$1,132	4
11 more payers between these — medians by payer and state Unlock with Pro →
Blue Cross Blue Shield of Kansas	$629	23
Anthem (Elevance)^†	$379	37
Blue Cross Blue Shield of North Dakota^†	$322	52

† Likely reflects a percent-of-billed-charge, case-rate, or per-diem contract structure rather than a comparable fee-schedule rate. See methodology.

Blue Cross Blue Shield (HCSC) pays a median of $3,238 for 43239 — 10.1× more than Blue Cross Blue Shield of North Dakota at $322. Caveat: percent-of-charge and per-diem contract artifacts can inflate or deflate MRF-derived medians; see methodology.

Payer-level medians are aggregated across all states each payer covers. Filter to your payer and state →

Rates by state

State-level negotiated medians for CPT 43239
State	Median	Coverage
MP	$1,026	Partial
PR	$942	Partial
VI	$942	Partial
OH	$939	Full
NE	$938	Full
All 56 states and territories, including yours Unlock with Pro →

Showing the 5 highest-median states. State medians are computed from payer-level medians; cells with fewer than 5 underlying rates are suppressed.

Methodology

The national median for 43239 is computed using a median-of-state-medians method: within each state we compute the median of all payer-reported in-network rates, then take the median of those state medians. This prevents high-volume states from dominating the national figure.

Cells with fewer than 5 underlying rates are suppressed before aggregation to prevent thin markets from distorting state or national summaries. An institutional billing class means rates reflect the facility fee schedule — what a hospital or ambulatory surgery center bills. The two billing classes are not directly comparable for the same procedure code.

All rates are derived from federally-mandated Transparency in Coverage Machine-Readable Files (45 CFR Part 147). We do not model, estimate, or invent prices — every figure traces back to a payer-published filing. A median is a summary, not a quote. No individual provider necessarily charges the median; percentile ranges exist precisely because prices vary. Verify specifics with your payer or provider. See our full methodology.

Payers contract under different structures (fee schedule, percent of billed charges, case rates); medians that diverge sharply from the national range usually reflect a different payment methodology rather than a genuinely different price.

Cite this data

CareCost Explorer, “Negotiated rate benchmarks for CPT 43239,” 2026-Q2 Transparency in Coverage data, carecostexplorer.com/benchmarks/procedure/43239. Generated 2026-06-12.

Journalists and researchers: this data is free to cite with attribution.

Frequently Asked Questions

What is the average negotiated rate for CPT 43239?

The national median negotiated rate for CPT 43239 (Egd biopsy single/multiple) is $835, computed from 752 rates across 17 payers and 56 states and territories. Individual payer medians range from $322 (Blue Cross Blue Shield of North Dakota) to $3,238 (Blue Cross Blue Shield (HCSC)). A median is a summary — your actual contracted rate depends on your specific payer and state.

Why do rates for CPT 43239 vary 10.1× between payers?

Negotiated rates are set individually between each payer and each provider network, so payer-level medians reflect different provider mixes, contract vintages, and market leverage. For CPT 43239, the top payer median ($3,238, Blue Cross Blue Shield (HCSC)) is 10.1× the bottom payer median ($322, Blue Cross Blue Shield of North Dakota). Percent-of-charge and per-diem contract structures can also inflate or deflate MRF-derived figures; see our methodology for details.

What does the institutional rate for CPT 43239 cover?

An institutional rate applies when CPT 43239 is billed under a facility fee schedule — typically by a hospital or ambulatory surgery center, not an individual clinician. The $835 national median reflects the facility component of the procedure. Patients may also receive a separate professional (clinician) bill. The institutional rate is filed under the insurer's facility in-network MRF and is distinct from the professional rate for the same procedure code.

How do I find my payer's rate for CPT 43239 in my state?

CareCost Explorer lets you filter by payer and state to see the specific negotiated median for your market. The data above shows payer-level medians aggregated across all states each payer covers; your state-specific rate may differ. Use the full Explorer tool at carecostexplorer.com/pricing to query your payer and geography directly.

Blue Cross Blue Shield (HCSC) pays a median of $3,238 for 43239 nationally. See the rate for your state →

See the rate for your payer, in your market.

Blue Cross Blue Shield (HCSC)'s median for 43239 is $3,238 — but your state and plan tell a different story. 36M+ rates, queryable.

Explore the full data →