Ascension Calumet Hospital, Inc.
614 Memorial Dr, Chilton, WI · Ascension · · NPI 1376541748
Published prices by procedure
Cash price is what you pay without insurance. The negotiated range spans the lowest to highest rate this hospital agreed with insurers.
| Procedure | Cash price | Gross charge | Negotiated range | Payers |
|---|---|---|---|---|
| X-ray head for orthodontia CPT 70350 | not published | not published | $8.96 – $23.23 | 7 |
| X-ray heel/calcaneus > 2 views (both sides) CPT 73650 | $62.70 | $110.00 | $8.23 – $19.72 | 7 |
| X-ray hip uni w/wo pelvis min 4 views CPT 73503 | not published | not published | $14.11 – $33.80 | 6 |
| X-ray hip with pelvis when performed bilateral 2 views CPT 73521 | $225.15 | $395.00 | $11.54 – $27.63 | 6 |
| X-ray hip with pelvis when performed bilateral 3-4 views CPT 73522 | $239.40 | $420.00 | $15.22 – $36.43 | 6 |
| X-ray hip with pelvis when performed bilateral >= 5 views CPT 73523 | $284.43 | $499.00 | $16.09 – $39.09 | 6 |
| X-ray hip with pelvis when performed unilateral 1 view left CPT 73501 | $107.73 | $189.00 | $9.69 – $23.19 | 6 |
| X-ray humerus >= 2 views left CPT 73060 | $152.19 | $267.00 | $8.23 – $20.56 | 7 |
| X-ray joint survey 1 view CPT 77077 | $136.80 | $240.00 | $17.54 – $42.01 | 7 |
| X-ray knee 1-2 views (both sides) CPT 73560 | $145.35 | $255.00 | $8.59 – $21.77 | 7 |
| X-ray knee 3 views (both sides) CPT 73562 | $159.03 | $279.00 | $9.69 – $23.19 | 7 |
| X-ray knee ap standing bilateral CPT 73565 | $137.37 | $241.00 | $8.59 – $22.55 | 7 |
| X-ray lower extremities infant > 2 views (both sides) CPT 73592 | $72.39 | $127.00 | $8.23 – $19.72 | 7 |
| X-ray l/s-spine bend vw only 2-3 vw CPT 72120 | $138.51 | $243.00 | $11.54 – $27.63 | 7 |
| X-ray lumbosacral spine >= 4 views CPT 72110 | $239.40 | $420.00 | $13.38 – $36.50 | 7 |
| X-ray lumbosacral spine complete including bending views >= 6 views CPT 72114 | $237.12 | $416.00 | $15.36 – $38.59 | 7 |
| X-ray male genital tract CPT 74440 | not published | not published | $18.93 – $45.34 | 7 |
| X-ray mandible complete > 4 views CPT 70110 | $80.37 | $141.00 | $12.65 – $31.15 | 7 |
| X-ray mandible ltd <4 views CPT 70100 | $74.10 | $130.00 | $9.33 – $22.35 | 7 |
| X-ray measurement of pelvis CPT 74710 | not published | not published | $17.47 – $42.06 | 7 |
| X-ray nasal bones complete > 3 views CPT 70160 | $75.81 | $133.00 | $8.60 – $21.45 | 7 |
| X-ray neck soft tissue CPT 70360 | $61.56 | $108.00 | $9.33 – $22.35 | 7 |
| X-ray nose to rectum for foreign body child CPT 76010 | $33.63 | $59.00 | $8.97 – $22.35 | 7 |
| X-ray of mammary ducts CPT 77054 | not published | not published | $22.73 – $55.30 | 7 |
| X-ray optic foramina CPT 70190 | not published | not published | $11.52 – $27.58 | 7 |
| X-ray pelvis 1-2 views CPT 72170 | $134.52 | $236.00 | $8.96 – $21.45 | 7 |
| X-ray pelvis complete > 3 views CPT 72190 | $168.72 | $296.00 | $13.01 – $31.15 | 7 |
| Xray place dist ext thor ao CPT 75959 | not published | not published | $0.02 – $394.36 | 7 |
| Xray place prox ext thor ao CPT 75958 | not published | not published | $0.02 – $458.27 | 7 |
| X-ray retrograde pyelogram with or without kidney ureter bladder w/supervision & interpretation CPT 74420 | not published | not published | $26.06 – $62.40 | 7 |
| X-ray ribs 2 views left CPT 71100 | $211.47 | $371.00 | $11.18 – $27.63 | 7 |
| X-ray ribs 3 views bilateral CPT 71110 | $422.37 | $741.00 | $14.86 – $36.43 | 7 |
| X-ray ribs w/posterior anterior chest 3 views left CPT 71101 | $243.39 | $427.00 | $13.76 – $32.96 | 7 |
| X-ray ribs w/posterior anterior chest > 4 views bilateral CPT 71111 | $422.37 | $741.00 | $16.46 – $39.98 | 7 |
| X-ray sacroiliac joints >= 3 views CPT 72202 | $78.09 | $137.00 | $11.55 – $28.52 | 7 |
| X-ray sacrum/coccyx >= 2 views CPT 72220 | $164.73 | $289.00 | $8.96 – $21.45 | 7 |
| X-ray scapula complete (both sides) CPT 73010 | $68.40 | $120.00 | $9.32 – $22.30 | 7 |
| X-ray sella turcica CPT 70240 | not published | not published | $9.70 – $24.08 | 7 |
| X-ray shoulder 1 view (both sides) CPT 73020 | $56.43 | $99.00 | $7.86 – $18.80 | 7 |
| X-ray sinuses paranasal complete > 3 views CPT 70220 | $84.36 | $148.00 | $11.18 – $29.06 | 7 |
| X-ray sinus tract/fistula/abscess CPT 76080 | not published | not published | $25.98 – $63.64 | 7 |
| X-ray skull < 4 views CPT 70250 | $149.34 | $262.00 | $9.33 – $29.01 | 7 |
| X-ray skull > 4 views complete CPT 70260 | $206.34 | $362.00 | $14.49 – $39.68 | 7 |
| X-ray slg plne bdy sect without urogr CPT 76100 | not published | not published | $29.49 – $74.60 | 7 |
| X-ray small bowel multi serial images abdominal radiographs(s)&delayed images single contrast study CPT 74250 | not published | not published | $40.68 – $99.42 | 7 |
| X-ray small intestine follow-through study CPT 74248 | not published | not published | $35.15 – $85.61 | 6 |
| X-ray spine single view CPT 72020 | $138.51 | $243.00 | $8.23 – $19.72 | 7 |
| X-ray sternoclavicular joint(s) > 3 views CPT 71130 | $49.59 | $87.00 | $11.18 – $27.63 | 7 |
| X-ray sternum > 2 views CPT 71120 | $67.83 | $119.00 | $10.08 – $24.97 | 7 |
| X-ray surgical specimen CPT 76098 | not published | not published | $16.09 – $38.52 | 7 |
| X-ray swallowing function w/ciner/videoradiography neck radiographs(s)&delayed images contrast study CPT 74230 | $170.43 | $299.00 | $26.91 – $65.00 | 7 |
| X-ray temporomandibular joint open/closed mouth bilateral CPT 70330 | not published | not published | $12.28 – $30.26 | 7 |
| X-ray thoracic spine 2 views CPT 72070 | $204.06 | $358.00 | $10.43 – $25.78 | 7 |
| X-ray thoracic spine 3 views CPT 72072 | $216.60 | $380.00 | $11.55 – $28.52 | 7 |
| X-ray thoracolumbar spine >=2 views CPT 72080 | $214.89 | $377.00 | $10.81 – $26.74 | 7 |
| X-ray thoracolumbar spine including skull cervical & sacral spine 1 view CPT 72081 | $107.73 | $189.00 | $13.38 – $32.91 | 6 |
| X-ray thoracolumbar spine including skull cervical & sacral spine 2-3 views CPT 72082 | $180.12 | $316.00 | $16.09 – $39.36 | 6 |
| X-ray tibia/fibula 2 views (both sides) CPT 73590 | $167.01 | $293.00 | $8.23 – $20.07 | 7 |
| X-ray toe(s) > 2 views (both sides) CPT 73660 | $72.39 | $127.00 | $6.75 – $16.17 | 7 |
| X-ray upper gastrointestinal tract scout abdominal radiographs delayed images double contrast CPT 74246 | not published | not published | $45.23 – $110.02 | 7 |
| X-ray upper gastrointestinal tract scout abdominal radiographs delayed images single contrast study CPT 74240 | not published | not published | $40.67 – $98.53 | 7 |
| X-ray upper gi delay w/kub CPT 74241 | not published | not published | $78.25 – $151.12 | 3 |
| X-ray upper gi&small intest CPT 74245 | not published | not published | $103.69 – $199.19 | 3 |
| X-ray wrist 2 views (both sides) CPT 73100 | $116.85 | $205.00 | $8.59 – $20.92 | 7 |
| X-ray xm phrnx&/crv esoph c+ CPT 74210 | not published | not published | $29.50 – $72.37 | 7 |
| Xtrnl ecg rec>48hr<7d CPT 93241 | not published | not published | $254.01 – $276.38 | 6 |
| Xtrnl ecg rec up to 48 hrs CPT 93224 | not published | not published | $76.99 – $288.42 | 7 |
| Xylose absorption test blood &/or urine CPT 84620 | not published | not published | $13.56 – $49.83 | 11 |
| Yersinia antibody CPT 86793 | not published | not published | $8.32 – $50.91 | 11 |
| Zika virus dna/rna amp probe CPT 87662 | not published | not published | $53.88 – $198.06 | 7 |
| Zika virus igm antibody CPT 86794 | not published | not published | $17.69 – $65.04 | 7 |
| Ziprasidone 20 mg/ml (final concentration) intramuscular solution HCPCS J3486 | $59.14 | $103.76 | $12.52 – $103.76 | 6 |
| Zoledronic acid 4 mg/5 ml intravenous solution HCPCS J3489 | $95.14 | $166.91 | $8.88 – $25.00 | 7 |
| Zoster vaccine-live inj CPT 90736 | $314.64 | $552.00 | $227.57 – $227.57 | 2 |
| Zrsr2 gene common variants CPT 81360 | not published | not published | $202.91 – $745.95 | 7 |
A missing value means the hospital did not publish that price — it never means the price is zero. Real bills can add facility fees, supplies and professional fees; see our methodology.