CMS Price Transparency Data

CT scan, pelvis

Facility: Mary Hitchcock Memorial Hospital

Billing Code: 72192 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 72192
Insurance Median: $293
Cash Discount Price: $575
vs. Medicare Baseline: 2.74x Medicare

The contracted insurance negotiated median rate for a CT scan, pelvis at Mary Hitchcock Memorial Hospital is $293. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $575. Compared to the federal Medicare reimbursement reference rate of $106.81, this hospital’s rate is 2.74x the Medicare baseline. Located in 1 Medical Center Drive, Lebanon, NH.

Cash / Self-Pay

$575

Average discount available for prompt cash payment at this facility.

Insurance Median

$293

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$106.81

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $106.81 (100%)

Cash / Self-Pay: $575 (538%)

Insurance Median: $293 (274%)

Cash: $575 (538% of Medicare)

Ins. Median: $293 (274% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $106.81 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 274% of the Medicare baseline (a markup of 174%). 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
Wellsense Health Plan	$44 - $342	41%
Blue Cross Blue Shield	$50 - $2,437	47%
Martin'S Point Generations Advantage	$50 - $119	47%
Mvp	$50 - $1,874	47%
UnitedHealthcare	$50 - $2,148	47%
Aetna	$51 - $1,963	48%
Cigna	$51 - $1,919	48%
Martin'S Point Health Care	$51 - $965	48%
Ambetter / Centene	$52 - $256	49%
Wellcare Health Plans	$52 - $124	49%
Harvard Pilgrim Health Care Of Ne	$62 - $1,794	58%
Beacon Health Strategies/Carelon	$78 - $342	73%
Amerihealth Caritas Nh	$80 - $317	75%
Granite State Health Plan	$80 - $352	75%
Mass General Brigham Health Plan	$144 - $1,740	135%
Tufts Health Plan	$167 - $1,632	156%
Maine Community Health Options	$613 - $2,056	574%
Coventry	$838 - $2,433	785%
First Health/Hcvm	$838 - $2,433	785%
Phcs	$867 - $2,517	812%
Corvel	$886 - $2,573	830%
Ccmsi	$915 - $2,657	857%

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 $575.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 72192.

Insurance In-Network Protection Plan

Contact your insurance company to confirm Mary Hitchcock Memorial Hospital is fully in-network.
Ask your insurer if "Prior Authorization" is required for CPT code 72192.
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.