CMS Price Transparency Data

Hip or knee replacement (inpatient stay)

Facility: Tomah Memorial Hospital

Billing Code: 470 (MS-DRG)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 470
Insurance Median: $70,334
Cash Discount Price: $48,094
vs. Medicare Baseline: 5.01x Medicare

The contracted insurance negotiated median rate for a Hip or knee replacement (inpatient stay) at Tomah Memorial Hospital is $70,334. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $48,094. Compared to the federal Medicare reimbursement reference rate of $14,044.15, this hospital’s rate is 5.01x the Medicare baseline. Located in 501 Gopher Dr, Tomah, WI.

Cash / Self-Pay

$48,094

Average discount available for prompt cash payment at this facility.

Insurance Median

$70,334

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$14,044.15

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $14,044.15 (100%)

Cash / Self-Pay: $48,094 (342%)

Insurance Median: $70,334 (501%)

Cash: $48,094 (342% of Medicare)

Ins. Median: $70,334 (501% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $14,044.15 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.

Elevated Commercial Rate Alert (Value-Gap)

The negotiated rate at this facility is 501% of the Medicare baseline (a markup of 401%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.

Consult Patient Advocate

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
Aetna	$12,101 - $71,095	86%
Blue Cross Blue Shield	$12,240 - $76,950	87%
Group Hlth Mcr Adv - All Plans	$12,240	87%
Humana	$12,240 - $77,368	87%
Independent Care Mcr - All Other Plans	$12,240	87%
Quartz Mcr Adv	$12,240	87%
Security Hp Mcr Adv	$12,240	87%
UnitedHealthcare	$12,240 - $78,873	87%
Va Ccn - All Plans	$12,240	87%
Cigna	$63,567 - $81,132	453%
Independent Care Mcaid	$70,334	501%
Managed Hlth Mcaid - All Plans	$70,334	501%
Quartz Mcaid	$70,334	501%
Security Hp Mcaid	$70,334	501%
Security Hp Comm - All Other Plans	$71,095	506%
Quartz Comm - All Other Plans	$75,277	536%
The Alliance - All Plans	$78,622	560%

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 $48,094.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify MS-DRG Code matches exactly: 470.

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 MS-DRG code 470.
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.