CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Valley West Community Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $2,570
Cash Discount Price: $6,777
vs. Medicare Baseline: 2.77x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Valley West Community Hospital is $2,570. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $6,777. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 2.77x the Medicare baseline. Located in 11 East Pleasant Avenue, Sandwich, IL.

Cash / Self-Pay

$6,777

Average discount available for prompt cash payment at this facility.

Insurance Median

$2,570

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: $6,777 (731%)

Insurance Median: $2,570 (277%)

Cash: $6,777 (731% of Medicare)

Ins. Median: $2,570 (277% 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 277% of the Medicare baseline (a markup of 177%). 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
Blue Cross Blue Shield	$306 - $3,756	33%
Cigna	$306 - $2,220	33%
Countycare Il Cook Co [1607]	$306	33%
Family Health Network Hmo [1610]	$306	33%
Medicaid / KanCare	$306	33%
Meridian Health Plan Hmo [1604]	$306	33%
Global Excel [1712]	$873	94%
Humana	$873	94%
Aetna	$1,168 - $3,186	126%
Health'S Finest Network [126]	$2,069 - $3,907	223%
UnitedHealthcare	$2,308 - $4,597	249%
The Alliance [1703]	$2,498	270%
Choicecare [177]	$3,098	334%
Healthlink [125]	$3,448	372%
Multiplan/Phcs [142]	$3,907 - $4,597	422%
First Health Plan [6034]	$4,597	496%

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 $6,777.
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 Valley West Community 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.