I know I'm not using the "new hotness" of PaaS startups, but my company runs entirely on a plain-vanilla Asterisk system that I first put together in 2004.
And I know I sound like a techno-hipster here, but it's been so easy to deal with that I didn't even upgrade past 1.4 until a year or so ago (and that was because of a bug -- I'm now on 1.8 and quite happy)
No GUI, no fancy FreePBX or Asterisk@Home, etc. Just a very very simple basic Asterisk box with the IVR/extension logic all hand-coded into .conf files.
The biggest change I made was moving the whole thing from a server sitting in the office to a VPS on Linode (that was pretty cool).
I use Aastra 57i handsets in the office - there may be better ones these days, but I've found Aastra to have the best compatibility with Asterisk (ps - open to suggestions if there are better ones!). I tried to get people to use SIP software on their iPhones but everyone loves having a desk phone and I haven't found any good SIP clients that work reliably.
It works flawlessly and people still wonder how we have such a flexible and easily changeable phone system that only costs me the price of the Linode + the handsets (and my time tinkering, of course). My favorite part is the infinite flexibility that having a programmable system gives us -- if someone in the office wants a feature, I just code it up, record some new prompts if necessary, and it's done.
For actual phone service, I used a very old-school hard POTS line into the server for a while, and fairly recently ported all the #s over to a SIP provider (FlowRoute). They've been fantastic, super cheap, super reliable, and super flexible. It's a service clearly designed for telephony nerds.
We have about 12 people who use this setup and here's some info on our volume (from FlowRoute):
Past 30 days:
6154 calls
14087 minutes
$253.34631000
(Much of that volume is from an 800#, hence the slightly higher cost)