CMS Price Transparency Data

Screening mammogram (both breasts)

Facility: Fort Memorial Hospital

Billing Code: 77067 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 77067
Insurance Median: $92
Cash Discount Price: $87
vs. Medicare Baseline: 0.73x Medicare

The contracted insurance negotiated median rate for a Screening mammogram (both breasts) at Fort Memorial Hospital is $92. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $87. Compared to the federal Medicare reimbursement reference rate of $126.25, this hospital’s rate is 0.73x the Medicare baseline. Located in 611 Sherman Ave E, Fort Atkinson, WI.

Cash / Self-Pay

$87

Average discount available for prompt cash payment at this facility.

Insurance Median

$92

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$126.25

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $126.25 (100%)

Cash / Self-Pay: $87 (69%)

Insurance Median: $92 (73%)

Cash: $87 (69% of Medicare)

Ins. Median: $92 (73% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $126.25 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	$19 - $300	15%
Dean Health Plan	$19 - $279	15%
Medicaid / KanCare	$19	15%
Quartz	$19 - $912	15%
UnitedHealthcare	$20 - $322	16%
Managed Health Services	$21 - $32	17%
Molina	$31 - $128	25%
Mercycare	$32 - $317	25%
Humana	$34 - $304	27%
Aetna	$55 - $319	44%
Centivo	$55 - $350	44%
Group Health Cooperative	$69 - $275	55%
Alliance	$93 - $305	74%
Trilogy	$100 - $374	79%
Cigna	$108 - $404	86%
Fort Care	$114 - $405	90%
Veteran Evaluation Services	$213	169%

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 $87.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 77067.

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 77067.
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.