CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Petaluma Valley Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $3,896
Cash Discount Price: $1,519
vs. Medicare Baseline: 4.20x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Petaluma Valley Hospital is $3,896. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $1,519. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 4.20x the Medicare baseline. Located in 400 N McDowell Blvd, Petaluma, CA.

Cash / Self-Pay

$1,519

Average discount available for prompt cash payment at this facility.

Insurance Median

$3,896

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: $1,519 (164%)

Insurance Median: $3,896 (420%)

Cash: $1,519 (164% of Medicare)

Ins. Median: $3,896 (420% 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 420% of the Medicare baseline (a markup of 320%). 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
Healthnet	$1,222 - $6,127	132%
Aetna	$1,247 - $11,153	135%
Blue Shield	$2,570 - $3,135	277%
UnitedHealthcare	$4,657 - $5,208	503%

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 $1,519.
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 Petaluma Valley 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.