CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: St Nicholas Hospital

Billing Code: 43239 (CPT)

The BaseRate · fair price high confidence

A fair price for this

$1,605

about 1.7× the $927 Medicare rate · typically $953–$2,691

modeled estimate · not a bill or quote

What this hospital charges insurers

$3,598

Well above the fair price

about $1,993 over the fair price · 3.9× Medicare

Medicare pays $927 Fair price $1,605 This hospital $3,598 Cash price $3,478 Hospital's list price $5,270

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 $116 Priciest $3,598

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

A fair price for a Upper endoscopy with biopsy is about $1,605 (about 1.7× the $927 Medicare rate). St Nicholas Hospital charges insurers about $3,598, or about $3,478 in cash — well 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 $1,605. 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	$906 - $4,378	98%
Blue Cross Blue Shieldmajor	$413 - $3,160	45%
Aetnamajor	$906 - $6,443	98%
Cignamajor	$2,868 - $4,510	310%
Humanamajor	$906 - $5,477	98%
Health Net	$4,036	436%
Medica	$906	98%
Meridian	$413	45%
Molina	$438 - $3,222	47%
Security Health Plan	$915 - $4,113	99%
+ 15 smaller / regional plans	$413 - $6,443

Government programs also on file: Medicare, Medicaid.

Excludes 6 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 3,478), 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: 43239.

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 43239.
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: Upper endoscopy with biopsy at other WI hospitals

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