SSM Health St. Agnes Hospital - Fond du Lac
430 E Division St, Fond Du Lac, WI · SSM Health · · NPI 1346228541
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 |
|---|---|---|---|---|
| Tbs techl prep&transmis data CPT 77090 | $144.65 | $263.00 | $7.70 – $166.13 | 4 |
| Tb test cell mediated immunity antigen response enumeration gamma interferon t-cells CPT 86481 | not published | not published | $75.00 – $193.00 | 7 |
| Tb test cell mediated immunity antigen response gamma interferon CPT 86480 | $202.40 | $368.00 | $46.48 – $119.62 | 7 |
| Tc-99m apcitide diag HCPCS A9504 | not published | not published | $1,386.10 – $1,386.10 | 1 |
| Tc-99m arcitumomab HCPCS A9568 | not published | not published | $2,203.89 – $2,203.89 | 1 |
| Tc-99m bicisate HCPCS A9557 | not published | not published | $581.64 – $1,861.65 | 5 |
| Tc-99m depreotide HCPCS A9536 | not published | not published | $2,110.89 – $2,110.89 | 1 |
| Tc-99m disofenin HCPCS A9510 | not published | not published | $162.92 – $162.92 | 1 |
| Tc-99m exame autol wbc diag per dose HCPCS A9569 | $784.85 | $1,427.00 | $700.60 – $2,832.27 | 5 |
| Tc-99m exametazime diag HCPCS A9521 | $717.20 | $1,304.00 | $2,184.37 – $2,184.37 | 1 |
| Tc-99m graphite crucible HCPCS A9506 | not published | not published | $246.45 – $894.61 | 5 |
| Tc-99m labeled rbc HCPCS A9560 | $245.30 | $446.00 | $287.08 – $287.08 | 1 |
| Tc-99m maa HCPCS A9540 | $476.85 | $867.00 | $80.16 – $80.16 | 1 |
| Tc-99m mebrofenin HCPCS A9537 | $121.00 | $220.00 | $308.90 – $308.90 | 1 |
| Tc-99m medronate HCPCS A9503 | $99.55 | $181.00 | $161.14 – $161.14 | 1 |
| Tc-99m mertiatide HCPCS A9562 | $452.10 | $822.00 | $2,091.51 – $2,091.51 | 1 |
| Tc-99m non-heu per study dose HCPCS Q9969 | $12.65 | $23.00 | $27.23 – $27.23 | 1 |
| Tc-99m oxidronate HCPCS A9561 | not published | not published | $137.38 – $137.38 | 1 |
| Tc-99m pentetate dtpa HCPCS A9539 | $172.70 | $314.00 | $68.69 – $68.69 | 1 |
| Tc-99m pentetate dtpa aerosol HCPCS A9567 | $173.80 | $316.00 | $55.49 – $55.49 | 1 |
| Tc-99m pertechnetate per mci HCPCS A9512 | $11.55 | $21.00 | $33.46 – $33.46 | 1 |
| Tc-99m pyroph diag per dose up to 25 mci HCPCS A9538 | not published | not published | $104.79 – $104.79 | 1 |
| Tc-99m sestamibi p study dose HCPCS A9500 | $190.85 | $347.00 | $1,226.71 – $1,226.71 | 1 |
| Tc-99m succimer (dmsa) HCPCS A9551 | not published | not published | $494.95 – $1,601.87 | 5 |
| Tc-99m sulfur colloid HCPCS A9541 | $118.25 | $215.00 | $2,045.69 – $2,045.69 | 1 |
| Tc-99m tetrofosmin p study dose HCPCS A9502 | $177.65 | $323.00 | $429.74 – $429.74 | 1 |
| Tc-99m tilmanocept diag HCPCS A9520 | $306.90 | $558.00 | not published | 0 |
| Tca peel dermal 15789 CPT 15789 | not published | not published | $548.27 – $2,334.00 | 6 |
| Tcd emboli detect w/inj CPT 93893 | not published | not published | $77.56 – $199.58 | 4 |
| Tcd emboli detect without inj CPT 93892 | not published | not published | $77.56 – $199.58 | 4 |
| T-cell depletion of harvest CPT 38210 | not published | not published | $327.28 – $2,334.00 | 6 |
| T cells absolute cd4/cd8 including ratio CPT 86360 | $389.40 | $708.00 | $35.24 – $90.67 | 7 |
| T cells absolute cd 4 count CPT 86361 | $226.05 | $411.00 | $20.08 – $51.69 | 7 |
| T cells total count CPT 86359 | $312.95 | $569.00 | $28.30 – $72.82 | 7 |
| Tcranial magn stim tx deli CPT 90868 | not published | not published | $160.18 – $412.19 | 4 |
| Tcranial magn stim tx plan CPT 90867 | not published | not published | $160.18 – $412.19 | 4 |
| Tcran magn stim redetemine CPT 90869 | not published | not published | $160.18 – $412.19 | 4 |
| Tdh sdrl/ventr pnxr CPT 61105 | not published | not published | $3,388.00 – $3,388.00 | 1 |
| Teaec w/wo patch graft iliofemoral CPT 35355 | not published | not published | $4,428.00 – $4,428.00 | 1 |
| Tebentafusp-tebn 100 mcg/0.5 ml intravenous solution HCPCS J9274 | not published | not published | $171.00 – $584.68 | 8 |
| Tee w or without fol w/cont,cong HCPCS C8926 | not published | not published | $581.54 – $1,496.49 | 4 |
| Tee w or without fol w/cont, mon HCPCS C8927 | not published | not published | $581.54 – $1,496.49 | 4 |
| Teflon or equal cable lining HCPCS L6665 | not published | not published | $42.28 – $108.81 | 4 |
| Telavancin injection HCPCS J3095 | not published | not published | $5.61 – $20.15 | 8 |
| Telehealth original site facility fee HCPCS Q3014 | $43.45 | $79.00 | not published | 0 |
| Telethx isodose plan cplx CPT 77307 | $2,137.30 | $3,886.00 | $277.76 – $714.78 | 4 |
| Telethx isodose plan simple CPT 77306 | $1,590.05 | $2,891.00 | $256.86 – $714.78 | 4 |
| Temozolomide HCPCS J8700 | not published | not published | $0.28 – $0.74 | 5 |
| Temozolomide 100 mg intravenous solution HCPCS J9328 | not published | not published | $7.81 – $28.35 | 8 |
| Temperature gradient studies CPT 93740 | not published | not published | $95.45 – $245.63 | 4 |
| Temsirolimus 30 mg/3 ml (10 mg/ml) (first dilution) intravenous soln HCPCS J9330 | not published | not published | $24.51 – $80.37 | 8 |
| Tendon lengthening CPT 26476 | not published | not published | $2,427.27 – $6,246.19 | 6 |
| Tendon lngth upr a/e ea tdn CPT 24305 | not published | not published | $2,427.27 – $8,770.00 | 6 |
| Tendon shortening CPT 26477 | not published | not published | $2,427.27 – $6,246.19 | 6 |
| Tendon transfer with graft CPT 26492 | not published | not published | $2,427.27 – $8,770.00 | 6 |
| Tenecteplase 5 mg/ml intravenous solution for ischemic stroke (50 mg vial) HCPCS J3101 | not published | not published | $163.07 – $442.22 | 8 |
| Teniposide, 50 mg HCPCS Q2017 | not published | not published | $8,154.27 – $8,154.27 | 1 |
| Tenodesis biceps tdn at elbw CPT 24340 | not published | not published | $5,382.89 – $16,106.00 | 6 |
| Tenolysis extensor tendon hand/finger each CPT 26445 | not published | not published | $2,427.27 – $6,246.19 | 6 |
| Tenolysis triceps CPT 24332 | not published | not published | $2,427.27 – $8,770.00 | 6 |
| Tenoplasty elbow to sho 1 CPT 24320 | not published | not published | $5,382.89 – $13,851.98 | 6 |
| Tenosynovectomy radic 26145 CPT 26145 | not published | not published | $1,192.86 – $4,761.00 | 6 |
| Tenotomy hip flexor open CPT 27005 | $5,657.85 | $10,287.00 | $2,427.27 – $18,364.00 | 6 |
| Tenotomy length/rls abductor hallucis musc 28240 CPT 28240 | not published | not published | $2,427.27 – $7,791.00 | 6 |
| Tenotomy open tndn flxr toe sgl tndn spx CPT 28232 | not published | not published | $1,192.86 – $7,791.00 | 6 |
| Tension based scoliosis orth HCPCS L1005 | not published | not published | $2,950.10 – $7,591.58 | 4 |
| Terbutaline 1 mg/ml subcutaneous solution HCPCS J3105 | not published | not published | $1.55 – $5.82 | 5 |
| Teriparatide injection HCPCS J3110 | not published | not published | $190.53 – $190.53 | 1 |
| Term dev auto grasp feature HCPCS L6881 | not published | not published | $3,775.59 – $9,715.85 | 4 |
| Term device, multi art digit HCPCS L6715 | not published | not published | $2,915.70 – $7,503.07 | 4 |
| Term dev mech hand vol close HCPCS L6709 | not published | not published | $1,284.16 – $3,304.57 | 4 |
| Term dev mech hand vol open HCPCS L6708 | not published | not published | $904.82 – $2,328.39 | 4 |
| Term dev mech hook vol close HCPCS L6707 | not published | not published | $1,368.79 – $3,522.35 | 4 |
| Term dev mech hook vol open HCPCS L6706 | not published | not published | $386.93 – $995.71 | 4 |
| Term dev modifier wrist unit HCPCS L6805 | not published | not published | $354.20 – $911.46 | 4 |
| Term dev, passive hand mitt HCPCS L6703 | not published | not published | $323.02 – $831.25 | 4 |
| Term dev precision pinch dev HCPCS L6810 | not published | not published | $188.30 – $484.55 | 4 |
| Term dev, sport/rec/work att HCPCS L6704 | not published | not published | $623.51 – $1,604.51 | 4 |
| Tert gene targeted seq alys CPT 81345 | not published | not published | $138.90 – $357.44 | 7 |
| Test for chlorohydrocarbons CPT 82441 | not published | not published | $4.51 – $11.60 | 7 |
| Test for porphobilinogen CPT 84106 | not published | not published | $4.36 – $11.23 | 7 |
| Test for urine cystines CPT 82615 | not published | not published | $7.16 – $18.43 | 7 |
| Testicular imaging w/vasc flow CPT 78761 | $1,936.00 | $3,520.00 | $296.56 – $763.16 | 4 |
| Testosterone response panel CPT 80414 | not published | not published | $38.73 – $99.67 | 7 |
| Testosterone undecanoate 1mg HCPCS J3145 | not published | not published | $1.61 – $5.23 | 8 |
| Test pathogen(s) for platelets reference HCPCS P9100 | not published | not published | $35.50 – $112.62 | 5 |
| Test sock elbw disart/above HCPCS L6682 | not published | not published | $314.03 – $808.11 | 4 |
| Test socket above knee HCPCS L5624 | not published | not published | $368.71 – $948.81 | 4 |
| Test socket below knee HCPCS L5620 | not published | not published | $273.78 – $704.53 | 4 |
| Test socket hemipelvectomy HCPCS L5628 | not published | not published | $591.08 – $1,521.05 | 4 |
| Test socket hip disarticulat HCPCS L5626 | not published | not published | $583.70 – $1,502.06 | 4 |
| Test socket knee disarticula HCPCS L5622 | not published | not published | $368.84 – $949.15 | 4 |
| Test socket shldr disart/tho HCPCS L6684 | not published | not published | $426.74 – $1,098.13 | 4 |
| Test socket symes HCPCS L5618 | not published | not published | $308.57 – $794.06 | 4 |
| Test sock wrist disart/bel e HCPCS L6680 | not published | not published | $284.03 – $730.91 | 4 |
| Test stress cardiovascular tracing only CPT 93017 | $1,001.55 | $1,821.00 | $160.18 – $412.19 | 4 |
| Test urine for lactose CPT 83633 | not published | not published | $8.44 – $21.71 | 7 |
| Test urine for porphyrins CPT 84119 | not published | not published | $10.02 – $25.78 | 7 |
| Test urine urobilinogen CPT 84578 | not published | not published | $3.35 – $8.63 | 7 |
| Tetanus ig im CPT 90389 | not published | not published | $2,120.83 – $2,120.83 | 1 |
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.