CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Tomah Memorial Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $319
Cash Discount Price: $364
vs. Medicare Baseline: 0.34x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Tomah Memorial Hospital is $319. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $364. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 0.34x the Medicare baseline. Located in 501 Gopher Dr, Tomah, WI.

Cash / Self-Pay

$364

Average discount available for prompt cash payment at this facility.

Insurance Median

$319

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: $364 (39%)

Insurance Median: $319 (34%)

Cash: $364 (39% of Medicare)

Ins. Median: $319 (34% 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
UnitedHealthcare	$98 - $192	11%
Blue Cross Blue Shield	$116 - $871	13%
Group Hlth Mcr Adv - All Plans	$116	13%
Independent Care Mcr - All Other Plans	$116	13%
Quartz Mcr Adv	$116	13%
Security Hp Mcr Adv	$116	13%
Va Ccn - All Plans	$116	13%
Aetna	$133 - $539	14%
Independent Care Mcaid	$319	34%
Managed Hlth Mcaid - All Plans	$319	34%
Quartz Mcaid	$319	34%
Security Hp Mcaid	$438	47%
The Alliance - All Plans	$492	53%
Security Hp Comm - All Other Plans	$539	58%
Quartz Comm - All Other Plans	$570	62%
Humana	$586	63%
Cigna	$615	66%

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 $364.
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 Tomah 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.