CMS Price Transparency Data

Upper endoscopy with biopsy

Facility: Stoughton Hospital

Billing Code: 43239 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 43239
Insurance Median: $279
Cash Discount Price: $1,476
vs. Medicare Baseline: 0.30x Medicare

The contracted insurance negotiated median rate for a Upper endoscopy with biopsy at Stoughton Hospital is $279. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $1,476. Compared to the federal Medicare reimbursement reference rate of $926.63, this hospital’s rate is 0.30x the Medicare baseline. Located in 900 Ridge St, Stoughton, WI.

Cash / Self-Pay

$1,476

Average discount available for prompt cash payment at this facility.

Insurance Median

$279

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: $1,476 (159%)

Insurance Median: $279 (30%)

Cash: $1,476 (159% of Medicare)

Ins. Median: $279 (30% 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
Healthnet Mcr Adv - All Plans	$98	11%
Tricare	$98	11%
Aetna	$116 - $2,094	13%
Dean Health Insurance Med Adv	$116	13%
Quartz Mcr Adv	$116	13%
Security Health/First Health - All Plans	$116	13%
UnitedHealthcare	$116 - $2,147	13%
Humana	$155 - $2,416	17%
Dean Health Insurance Comm - All Other Plans	$264	28%
Dean Health Insurance Epo	$264	28%
Quartz Health Solutions - All Other Lans	$279	30%
Alliance - All Plans	$428	46%
Blue Cross Blue Shield	$592	64%
Medicaid / KanCare	$657	71%
Geha - All Plans	$2,013	217%
Cigna	$2,147	232%
Wisconsin Ppo Ppa Direct - All Plans	$2,147	232%
Wps - All Plans	$3,603	389%

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 $1,476.
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 Stoughton 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.