CMS Price Transparency Data

Sepsis treatment (inpatient stay)

Facility: Tomah Memorial Hospital

Billing Code: 871 (MS-DRG)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 871
Insurance Median: $18,847
Cash Discount Price: $12,887
vs. Medicare Baseline: 1.34x Medicare

The contracted insurance negotiated median rate for a Sepsis treatment (inpatient stay) at Tomah Memorial Hospital is $18,847. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $12,887. Compared to the federal Medicare reimbursement reference rate of $14,116.91, this hospital’s rate is 1.34x the Medicare baseline. Located in 501 Gopher Dr, Tomah, WI.

Cash / Self-Pay

$12,887

Average discount available for prompt cash payment at this facility.

Insurance Median

$18,847

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$14,116.91

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $14,116.91 (100%)

Cash / Self-Pay: $12,887 (91%)

Insurance Median: $18,847 (134%)

Cash: $12,887 (91% of Medicare)

Ins. Median: $18,847 (134% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $14,116.91 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
Aetna	$16,135 - $19,051	114%
Blue Cross Blue Shield	$16,319 - $20,620	116%
Group Hlth Mcr Adv - All Plans	$16,319	116%
Humana	$16,319 - $20,732	116%
Independent Care Mcr - All Other Plans	$16,319	116%
Quartz Mcr Adv	$16,319	116%
Security Hp Mcr Adv	$16,319	116%
UnitedHealthcare	$16,319 - $21,135	116%
Va Ccn - All Plans	$16,319	116%
Cigna	$17,034 - $21,740	121%
Independent Care Mcaid	$18,847	134%
Managed Hlth Mcaid - All Plans	$18,847	134%
Quartz Mcaid	$18,847	134%
Security Hp Mcaid	$18,847	134%
Security Hp Comm - All Other Plans	$19,051	135%
Quartz Comm - All Other Plans	$20,171	143%
The Alliance - All Plans	$21,068	149%

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 $12,887.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify MS-DRG Code matches exactly: 871.

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 871.
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.