CMS Price Transparency Data

Office visit, established patient (20-29 min)

Facility: St Nicholas Hospital

Billing Code: 99213 (CPT)

The BaseRate · fair price high confidence

A fair price for this

$84

about 0.9× the $95 Medicare rate · typically $68–$186

modeled estimate · not a bill or quote

What this hospital charges insurers

$113

Above the fair price

about $29 over the fair price · 1.2× Medicare

Medicare pays $95 Fair price $84 This hospital $113 Cash price $244 Hospital's list price $369

How we calculate the fair BaseRate →

How this hospital compares to other WI hospitals

Highest price of the 9 WI hospitals we have prices for — worth calling around.

Cheapest $60 Priciest $113

Black dot = this hospital, among the 9 WI hospitals with a price for this procedure. Full list below.

A fair price for a Office visit, established patient (20-29 min) is about $84 (about 0.9× the $95 Medicare rate). St Nicholas Hospital charges insurers about $113, or about $244 in cash — above the fair price. Located in Sheboygan, WI.

This price is above the fair BaseRate — you may be able to pay less

Ask the hospital for the cash / self-pay price, check whether you qualify for financial assistance, or negotiate the bill down toward the fair price of about $84. Many patients pay well below the first number they’re quoted — the checklists below walk you through it.

What each insurance company pays

Which insurers have negotiated a price with this hospital for this procedure — and which haven’t.

5 of 6 major insurers have a published price at this hospital

✓ UnitedHealthcare✓ Blue Cross Blue Shield✓ Aetna✓ Cigna✓ Humana Kaiser Permanente

Crossed out = this hospital hasn’t published a negotiated price for that insurer for this procedure. It doesn’t necessarily mean they aren’t accepted — ask your insurer.

Insurance company	Price range	vs. Medicare
UnitedHealthcaremajor	$90 - $95	95%
Blue Cross Blue Shieldmajor	$126 - $159	132%
Aetnamajor	$369	388%
Cignamajor	$258	271%
Humanamajor	$113 - $314	119%
Health Net	$221	232%
Molina	$184	193%
Security Health Plan	$236	248%
+ 13 smaller / regional plans	$179 - $369

Excludes 5 rental-network / third-party entries (e.g. Multiplan, PHCS) — these are pricing networks, not insurers.

Self-Pay How to get the cash price

Tell the billing desk you want to be billed as self-pay — not through insurance — before your visit.
Ask for the cash / prompt-pay discount in writing, with the exact price (about 244), before you agree to anything.
Get it in writing that they won’t also bill your insurance, so the cash price is what you owe.
Check the CPT code on your bill matches exactly: 99213.

Insurance Before you use insurance

Call your insurance company to confirm St Nicholas Hospital is in-network.
Ask your insurer whether prior approval is required for CPT code 99213.
Confirm the doctor or provider is in-network too — not just the hospital building.
Check your Explanation of Benefits against the hospital’s final itemized bill.

Estimate your out-of-pocket cost

A rough estimate of what you’d pay with insurance (deductible + coinsurance) versus paying the cash price yourself.

How you’d pay

Deductible left to meet ($)

Your coinsurance (%)

Enter your details and press estimate to compare.

Other Procedures at St Nicholas Hospital

Compare: Office visit, established patient (20-29 min) at other WI hospitals

Insurance negotiated median for the same procedure, sorted lowest first.