Drm agrft t/a/l ea addl cost in Wisconsin

DRM AGRFT T/A/L EA ADDL · CPT 15131

Hospital	City	Cash price	Negotiated range	Payers
Ascension SE Wisconsin Hospital - St. Joseph Campus	Milwaukee	not published	$363.08 – $363.08	1
SSM Health Ripon Community Hospital	Ripon	not published	$1,887.00 – $5,512.00	3
SSM Health Monroe Hospital	Monroe	not published	$2,181.00 – $9,837.00	2
Ascension St. Francis Hospital, Inc.	Milwaukee	not published	$363.08 – $363.08	1
Ascension NE Wisconsin - Mercy Campus (Ascension NE Wisconsin, Inc.)	Oshkosh	not published	$90.65 – $354.75	7
Orthopaedic Hospital of Wisconsin, LLC	Glendale	not published	$949.00 – $16,897.00	6
UnityPoint Health - Meriter Hospital	Madison	not published	$79.69 – $266.16	10
SSM Health St. Mary's Hospital - Madison	Madison	not published	$2,036.00 – $2,036.00	1
Ascension Columbia St. Mary's Hospital - Milwaukee Campus (Columbia St. Mary's Hospital Milwaukee, Inc.)	Milwaukee	not published	$140.01 – $387.86	6
Ascension Columbia St. Mary's Hospital - Ozaukee Campus (Columbia St. Mary's Hospital Milwaukee, Inc.)	Mequon	not published	$140.01 – $387.86	6
Midwest Orthopedic Specialty Hospital	Franklin	not published	$363.08 – $363.08	1
SSM Health St. Mary's Hospital - Janesville	Janesville	not published	$1,704.00 – $1,704.00	1
SSM Health St. Clare Hospital - Baraboo	Baraboo	not published	$1,676.00 – $1,676.00	1
Ascension Calumet Hospital, Inc.	Chilton	not published	$90.65 – $354.75	7
Ascension NE Wisconsin - St. Elizabeth Campus (Ascension NE Wisconsin, Inc.)	Appleton	not published	$90.65 – $354.75	7
SSM Health Waupun Memorial Hospital	Waupun	not published	$1,887.00 – $5,512.00	3
SSM Health St. Agnes Hospital - Fond du Lac	Fond Du Lac	not published	$1,887.00 – $5,512.00	3