CMS Price Transparency Data

CT scan, pelvis

Facility: Tomah Memorial Hospital

Billing Code: 72192 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 72192
Insurance Median: $655
Cash Discount Price: $884
vs. Medicare Baseline: 6.13x Medicare

The contracted insurance negotiated median rate for a CT scan, pelvis at Tomah Memorial Hospital is $655. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $884. Compared to the federal Medicare reimbursement reference rate of $106.81, this hospital’s rate is 6.13x the Medicare baseline. Located in 501 Gopher Dr, Tomah, WI.

Cash / Self-Pay

$884

Average discount available for prompt cash payment at this facility.

Insurance Median

$655

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: $884 (828%)

Insurance Median: $655 (613%)

Cash: $884 (828% of Medicare)

Ins. Median: $655 (613% 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 613% of the Medicare baseline (a markup of 513%). 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
UnitedHealthcare	$34 - $1,817	32%
Blue Cross Blue Shield	$48 - $1,772	45%
Group Hlth Mcr Adv - All Plans	$48 - $655	45%
Independent Care Mcr - All Other Plans	$48 - $655	45%
Quartz Mcr Adv	$48 - $655	45%
Security Hp Mcr Adv	$48 - $655	45%
Va Ccn - All Plans	$48 - $655	45%
Aetna	$55 - $1,638	51%
Independent Care Mcaid	$169 - $235	158%
Managed Hlth Mcaid - All Plans	$169 - $235	158%
Quartz Mcaid	$169 - $235	158%
Security Hp Mcaid	$169 - $235	158%
The Alliance - All Plans	$244 - $11,463	228%
Humana	$655 - $1,782	613%
Security Hp Comm - All Other Plans	$976 - $1,638	914%
Quartz Comm - All Other Plans	$1,033 - $1,734	967%
Cigna	$1,114 - $1,869	1043%

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 $884.
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 Tomah 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.