CMS Price Transparency Data

Colonoscopy with biopsy

Facility: St Nicholas Hospital

Billing Code: 45380 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 45380
Insurance Median: $2,943
Cash Discount Price: $2,697
vs. Medicare Baseline: 2.41x Medicare

The contracted insurance negotiated median rate for a Colonoscopy with biopsy at St Nicholas Hospital is $2,943. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $2,697. Compared to the federal Medicare reimbursement reference rate of $1,222.56, this hospital’s rate is 2.41x the Medicare baseline. Located in 3100 Superior Ave, Sheboygan, WI.

Cash / Self-Pay

$2,697

Average discount available for prompt cash payment at this facility.

Insurance Median

$2,943

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$1,222.56

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $1,222.56 (100%)

Cash / Self-Pay: $2,697 (221%)

Insurance Median: $2,943 (241%)

Cash: $2,697 (221% of Medicare)

Ins. Median: $2,943 (241% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $1,222.56 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 241% of the Medicare baseline (a markup of 141%). 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	$422 - $4,087	35%
Community Care Family Care	$422	35%
Managed Health Services	$422	35%
Medicaid / KanCare	$422	35%
Meridian Health Plan	$422	35%
Molina Healthcare	$448 - $1,140	37%
Triology	$448 - $3,229	37%
Aetna	$1,140 - $4,087	93%
Humana	$1,140 - $4,087	93%
Medica	$1,140	93%
Medicare (plans)	$1,140	93%
UnitedHealthcare	$1,140 - $4,087	93%
Security Health Plan	$1,151 - $2,609	94%
Molina Healthcare Of Wi	$2,043	167%
Hshs Employees	$2,215	181%
Arise Health Plan	$2,452	201%
Wea Provider Network	$2,534 - $2,942	207%
Naphcare	$2,564	210%
Cigna	$2,861	234%
Interplan	$2,861	234%
Network Health Plan	$2,861	234%
Health Care Alliance	$2,983	244%
Health Eos	$3,065	251%
Healthsmart	$3,065	251%
Wisconsin Physician Service	$3,269	267%
Multiplan/Phcs	$3,433	281%
Choicecare	$3,474	284%
North Central Healthcare Alliance	$3,760	308%
First Health	$3,882	318%
P360 Small Group	$4,036	330%
Prevea Health Network	$4,036	330%
Caterpillar, Inc.	$4,087	334%
Cofinity	$4,087	334%
Live360	$4,087	334%

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 $2,697.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 45380.

Insurance In-Network Protection Plan

Contact your insurance company to confirm St Nicholas Hospital is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 45380.
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.