CMS Price Transparency Data

CT scan, pelvis

Facility: Fort Memorial Hospital

Billing Code: 72192 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 72192
Insurance Median: $115
Cash Discount Price: $468
vs. Medicare Baseline: 1.08x Medicare

The contracted insurance negotiated median rate for a CT scan, pelvis at Fort Memorial Hospital is $115. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $468. Compared to the federal Medicare reimbursement reference rate of $106.81, this hospital’s rate is 1.08x the Medicare baseline. Located in 611 Sherman Ave E, Fort Atkinson, WI.

Cash / Self-Pay

$468

Average discount available for prompt cash payment at this facility.

Insurance Median

$115

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: $468 (438%)

Insurance Median: $115 (108%)

Cash: $468 (438% of Medicare)

Ins. Median: $115 (108% 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.

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
Blue Cross Blue Shield	$42 - $955	39%
Dean Health Plan	$44 - $800	41%
Medicaid / KanCare	$44	41%
Quartz	$44 - $1,339	41%
UnitedHealthcare	$45 - $156	42%
Mercycare	$46 - $1,899	43%
Humana	$48 - $243	45%
Managed Health Services	$48 - $53	45%
Molina	$48 - $134	45%
Aetna	$100 - $1,913	94%
Medicare (plans)	$102	95%
Veteran Evaluation Services	$127	119%
Alliance	$133 - $1,830	125%
Fort Care	$162 - $429	152%
Centivo	$165 - $1,050	154%
Group Health Cooperative	$206 - $1,650	193%
Trilogy	$299 - $2,243	280%
Cigna	$323 - $2,423	302%

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 $468.
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 Fort 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.