CMS Price Transparency Data

CT scan, abdomen and pelvis (with contrast)

Facility: Tomah Memorial Hospital

Billing Code: 74177 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 74177
Insurance Median: $638
Cash Discount Price: $1,668
vs. Medicare Baseline: 1.79x Medicare

The contracted insurance negotiated median rate for a CT scan, abdomen and pelvis (with contrast) at Tomah Memorial Hospital is $638. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $1,668. Compared to the federal Medicare reimbursement reference rate of $356.43, this hospital’s rate is 1.79x the Medicare baseline. Located in 501 Gopher Dr, Tomah, WI.

Cash / Self-Pay

$1,668

Average discount available for prompt cash payment at this facility.

Insurance Median

$638

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$356.43

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $356.43 (100%)

Cash / Self-Pay: $1,668 (468%)

Insurance Median: $638 (179%)

Cash: $1,668 (468% of Medicare)

Ins. Median: $638 (179% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $356.43 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	$56 - $4,764	16%
Blue Cross Blue Shield	$80 - $4,648	22%
Group Hlth Mcr Adv - All Plans	$80 - $1,718	22%
Independent Care Mcr - All Other Plans	$80 - $1,718	22%
Quartz Mcr Adv	$80 - $1,718	22%
Security Hp Mcr Adv	$80 - $1,718	22%
Va Ccn - All Plans	$80 - $1,718	22%
Aetna	$92 - $4,294	26%
Independent Care Mcaid	$247 - $520	69%
Managed Hlth Mcaid - All Plans	$247 - $520	69%
Quartz Mcaid	$247 - $520	69%
Security Hp Mcaid	$247 - $520	69%
The Alliance - All Plans	$410 - $30,061	115%
Security Hp Comm - All Other Plans	$638 - $4,294	179%
Quartz Comm - All Other Plans	$675 - $4,547	189%
Humana	$694 - $4,673	195%
Cigna	$728 - $4,901	204%

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 $1,668.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 74177.

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 74177.
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.