CMS Price Transparency Data

Office visit, established patient (30-39 min)

Facility: Tomah Memorial Hospital

Billing Code: 99214 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 99214
Insurance Median: $194
Cash Discount Price: $138
vs. Medicare Baseline: 1.43x Medicare

The contracted insurance negotiated median rate for a Office visit, established patient (30-39 min) at Tomah Memorial Hospital is $194. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $138. Compared to the federal Medicare reimbursement reference rate of $135.6, this hospital’s rate is 1.43x the Medicare baseline. Located in 501 Gopher Dr, Tomah, WI.

Cash / Self-Pay

$138

Average discount available for prompt cash payment at this facility.

Insurance Median

$194

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$135.6

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $135.6 (100%)

Cash / Self-Pay: $138 (102%)

Insurance Median: $194 (143%)

Cash: $138 (102% of Medicare)

Ins. Median: $194 (143% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $135.6 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	$32 - $1,166	24%
Group Hlth Mcr Adv - All Plans	$47 - $420	35%
Quartz Mcr Adv	$48 - $420	35%
Aetna	$68 - $1,051	50%
Security Hp Comm - All Other Plans	$68 - $1,051	50%
Quartz Comm - All Other Plans	$72 - $1,112	53%
Humana	$74 - $1,143	55%
Cigna	$78 - $1,199	58%
Blue Cross Blue Shield	$82 - $1,137	60%
Independent Care Mcr - All Other Plans	$82 - $420	60%
Security Hp Mcr Adv	$82 - $420	60%
Va Ccn - All Plans	$82 - $420	60%
Independent Care Mcaid	$86	63%
Managed Hlth Mcaid - All Plans	$86	63%
Quartz Mcaid	$86	63%
Security Hp Mcaid	$86	63%
The Alliance - All Plans	$137 - $1,149	101%

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 $138.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 99214.

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 99214.
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.