CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Fort Memorial Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $1,377
Cash Discount Price: $1,125
vs. Medicare Baseline: 1.49x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Fort Memorial Hospital is $1,377. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $1,125. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 1.49x the Medicare baseline. Located in 611 Sherman Ave E, Fort Atkinson, WI.

Cash / Self-Pay

$1,125

Average discount available for prompt cash payment at this facility.

Insurance Median

$1,377

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: $1,125 (121%)

Insurance Median: $1,377 (149%)

Cash: $1,125 (121% of Medicare)

Ins. Median: $1,377 (149% 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.

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
Molina	$134 - $904	14%
UnitedHealthcare	$167 - $904	18%
Humana	$378 - $8,014	41%
Blue Cross Blue Shield	$416 - $2,242	45%
Dean Health Plan	$416 - $5,393	45%
Medicaid / KanCare	$416	45%
Quartz	$416 - $1,326	45%
Fort Care	$419	45%
Managed Health Services	$453	49%
Group Health Cooperative	$649 - $2,291	70%
Medicare (plans)	$904	98%
Veteran Evaluation Services	$1,049	113%
Aetna	$1,377 - $2,656	149%
Centivo	$2,014 - $2,098	217%
Alliance	$2,450 - $2,541	264%
Mercycare	$2,541 - $2,636	274%
Trilogy	$3,002 - $3,114	324%
Cigna	$3,243 - $3,364	350%

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 $1,125.
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 Fort Memorial 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.