Chmotx admn plrl cav thrcnts cost in Wisconsin

CHMOTX ADMN PLRL CAV THRCNTS · CPT 96440

Hospital	City	Cash price	Negotiated range	Payers
UnityPoint Health - Meriter Hospital	Madison	not published	$125.28 – $537.45	10
Ascension Columbia St. Mary's Hospital - Ozaukee Campus (Columbia St. Mary's Hospital Milwaukee, Inc.)	Mequon	not published	$322.89 – $3,284.19	9
Ascension Columbia St. Mary's Hospital - Milwaukee Campus (Columbia St. Mary's Hospital Milwaukee, Inc.)	Milwaukee	not published	$322.89 – $3,284.19	9
SSM Health St. Mary's Hospital - Madison	Madison	not published	$240.63 – $320.84	2
SSM Health St. Mary's Hospital - Janesville	Janesville	not published	$249.53 – $332.70	2
SSM Health St. Clare Hospital - Baraboo	Baraboo	not published	$240.63 – $320.84	2
SSM Health St. Agnes Hospital - Fond du Lac	Fond Du Lac	not published	$245.03 – $630.55	4
SSM Health Monroe Hospital	Monroe	not published	$320.84 – $320.84	1
Ascension St. Francis Hospital, Inc.	Milwaukee	not published	$322.08 – $2,787.76	4
Ascension SE Wisconsin Hospital - St. Joseph Campus	Milwaukee	not published	$322.08 – $2,787.76	4
Ascension NE Wisconsin - Mercy Campus (Ascension NE Wisconsin, Inc.)	Oshkosh	not published	$143.20 – $3,001.22	12
Ascension NE Wisconsin - St. Elizabeth Campus (Ascension NE Wisconsin, Inc.)	Appleton	not published	$143.20 – $3,001.22	12
Ascension Calumet Hospital, Inc.	Chilton	not published	$143.20 – $3,001.22	7
Midwest Orthopedic Specialty Hospital	Franklin	not published	$322.08 – $2,787.76	4