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 |
|---|---|---|---|---|
| Unlisted px middle ear CPT 69799 | not published | not published | $175.70 – $2,334.00 | 6 |
| Unlisted px neck/thorax CPT 21899 | not published | not published | $175.70 – $2,334.00 | 6 |
| Unlisted px palate uvula CPT 42299 | not published | not published | $175.70 – $2,334.00 | 6 |
| Unlisted px pelvis/hip joint CPT 27299 | not published | not published | $182.99 – $2,334.00 | 6 |
| Unlisted px posterior segmnt CPT 67299 | not published | not published | $1,712.02 – $4,761.00 | 6 |
| Unlisted px salivry glnd/dux CPT 42699 | not published | not published | $175.70 – $2,334.00 | 6 |
| Unlisted px small intestine CPT 44799 | not published | not published | $672.83 – $4,761.00 | 6 |
| Unlisted px temporal bone CPT 69979 | not published | not published | $175.70 – $2,334.00 | 6 |
| Unlisted px ther rad tx plng CPT 77299 | not published | not published | $99.71 – $256.58 | 4 |
| Unlisted px tongue flr mouth CPT 41599 | $372.35 | $677.00 | $175.70 – $2,334.00 | 6 |
| Unlisted px vestibule mouth CPT 40899 | not published | not published | $175.70 – $2,334.00 | 6 |
| Unlisted reprod med lab proc CPT 89398 | not published | not published | $38.66 – $99.48 | 5 |
| Unlisted resp px dx nuc med CPT 78599 | not published | not published | $296.56 – $763.16 | 4 |
| Unlisted spec derm svc/px CPT 96999 | not published | not published | $148.84 – $383.01 | 4 |
| Unlisted special svc px/rprt CPT 99199 | $205.15 | $373.00 | not published | 0 |
| Unlisted surgical path px CPT 88399 | not published | not published | $38.66 – $99.48 | 5 |
| Unlisted transfusion med px CPT 86999 | $73.70 | $134.00 | $21.46 – $55.21 | 5 |
| Unlisted ultrasound procedure CPT 76999 | $400.95 | $729.00 | $64.56 – $166.13 | 4 |
| Unlisted vasc endoscopy px CPT 37501 | not published | not published | $465.35 – $3,030.00 | 6 |
| Unlstd hematop ret/endo lymp CPT 78199 | not published | not published | $296.56 – $763.16 | 4 |
| Unlstd laps px mat care&dlvr CPT 59898 | not published | not published | $4,484.77 – $16,106.00 | 6 |
| Unlstd laps px sprmatic cord CPT 55559 | not published | not published | $4,484.77 – $16,106.00 | 6 |
| Unsched dialysis esrd pt hos HCPCS G0257 | $680.90 | $1,238.00 | not published | 0 |
| Upgrade pm system CPT 33214 | $3,135.55 | $5,701.00 | $7,609.00 – $43,643.00 | 6 |
| Upper Back (Thoracic Spine) MRI (with and without contrast) CPT 72157 | $2,419.45 | $4,399.00 | $258.81 – $665.99 | 4 |
| Upper Back (Thoracic Spine) MRI (with contrast) CPT 72147 | $2,303.95 | $4,189.00 | $258.81 – $665.99 | 4 |
| Upper Back (Thoracic Spine) MRI (without contrast) CPT 72146 | $2,194.50 | $3,990.00 | $177.00 – $455.49 | 4 |
| Upper Endoscopy (EGD, diagnostic) CPT 43235 | $361.35 | $657.00 | $672.83 – $4,761.00 | 7 |
| Upper Endoscopy (EGD, with biopsy) CPT 43239 | not published | not published | $672.83 – $4,761.00 | 7 |
| Upper ext fx orthosis rad/ul HCPCS L3982 | not published | not published | $329.51 – $847.95 | 4 |
| Upper ext harvest for cabg1 seg 35600 CPT 35600 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Uppr gi scope w/submuc inj CPT 43236 | not published | not published | $672.83 – $4,761.00 | 6 |
| Urachal cyst/sinus excision 51500 CPT 51500 | not published | not published | $4,484.77 – $11,540.80 | 6 |
| Urea nitrogen CPT 84520 | $47.85 | $87.00 | $2.96 – $7.62 | 7 |
| Urea nitrogen 24 hour urine CPT 84540 | $46.75 | $85.00 | $4.17 – $10.73 | 7 |
| Urea nitrogen clearance CPT 84545 | not published | not published | $5.40 – $13.90 | 7 |
| Urea nitrogen semi-quant CPT 84525 | not published | not published | $3.85 – $9.90 | 7 |
| Ureteral embolization/occl CPT 50705 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Ureteral reflux study CPT 78740 | $1,936.00 | $3,520.00 | $296.56 – $763.16 | 4 |
| Ureter endoscopy CPT 50970 | not published | not published | $2,614.94 – $6,729.12 | 6 |
| Ureter endoscopy & biopsy CPT 50955 | not published | not published | $3,977.55 – $10,235.57 | 6 |
| Ureter endoscopy & biopsy CPT 50974 | not published | not published | $3,579.00 – $10,235.57 | 6 |
| Ureter endoscopy & catheter CPT 50972 | not published | not published | $2,614.94 – $6,729.12 | 6 |
| Ureter endoscopy & treatment CPT 50957 | not published | not published | $3,977.55 – $10,235.57 | 6 |
| Ureter endoscopy & treatment CPT 50961 | not published | not published | $3,977.55 – $10,235.57 | 6 |
| Ureter endoscopy & treatment CPT 50976 | not published | not published | $3,579.00 – $10,235.57 | 6 |
| Ureter endoscopy & treatment CPT 50980 | not published | not published | $3,977.55 – $10,235.57 | 6 |
| Ureteroneocystostomy 50780 CPT 50780 | not published | not published | $3,735.00 – $7,791.00 | 3 |
| Ureteroureterostomy 50760 CPT 50760 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Urethrcystgrphy rtrgrde s&i CPT 74450 | $457.60 | $832.00 | $177.00 – $455.49 | 4 |
| Urethrlys transvag with scope CPT 53500 | not published | not published | $2,614.94 – $8,770.00 | 6 |
| Urethrocystography void s&i CPT 74455 | $457.60 | $832.00 | $177.00 – $455.49 | 4 |
| Uric acid blood CPT 84550 | $40.15 | $73.00 | $3.39 – $8.72 | 7 |
| Uric acid urine CPT 84560 | $46.75 | $85.00 | $3.81 – $9.80 | 7 |
| Urinalysis glass test CPT 81020 | not published | not published | $3.52 – $9.07 | 7 |
| Urinalysis microscopic only CPT 81015 | $25.85 | $47.00 | $2.29 – $5.89 | 7 |
| Urinalysis qual/semiquant excpt ia CPT 81005 | not published | not published | $1.63 – $4.19 | 7 |
| Urinalysis (with microscopy) CPT 81001 | $57.75 | $105.00 | $2.38 – $6.12 | 7 |
| Urinalysis (without microscopy) CPT 81003 | $24.75 | $45.00 | $1.69 – $4.34 | 7 |
| Urinary bldr retent nuc study CPT 78730 | not published | not published | $237.15 – $237.15 | 1 |
| Urinary reflex study CPT 51792 | not published | not published | $43.76 – $2,334.00 | 6 |
| Urine Culture Test CPT 87086 | $88.00 | $160.00 | $6.05 – $15.58 | 7 |
| Urine flow measurement 51736 CPT 51736 | not published | not published | $98.70 – $2,334.00 | 6 |
| Urine pregnancy test CPT 81025 | $58.30 | $106.00 | $6.46 – $16.62 | 7 |
| Urine screen for bacteria CPT 81007 | not published | not published | $5.20 – $57.86 | 7 |
| Urine shunt to intestine CPT 50815 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Urine specimen collect mult HCPCS P9615 | not published | not published | $3.00 – $15.91 | 4 |
| Urofollitropin, 75 iu HCPCS J3355 | not published | not published | $161.14 – $161.14 | 1 |
| Urography, antegrade CPT 74425 | $366.30 | $666.00 | $258.81 – $665.99 | 4 |
| Urography inf drip &/or bolus CPT 74410 | not published | not published | $130.12 – $334.84 | 4 |
| Use 1st target lesion CPT 76982 | $207.35 | $377.00 | $77.56 – $199.58 | 4 |
| User adjustable heel height HCPCS L5990 | not published | not published | $1,675.40 – $4,311.37 | 4 |
| Ustekinumab 130 mg/26 ml intravenous solution HCPCS J3358 | not published | not published | $8.52 – $34.73 | 8 |
| Ustekinumab 45 mg/0.5 ml subcutaneous solution HCPCS J3357 | not published | not published | $168.78 – $424.38 | 3 |
| U/s trtmt, not leiomyomata HCPCS C9734 | not published | not published | $7,529.00 – $24,508.80 | 6 |
| Vaccine covid-19 moderna >=12yrs 50mcg/0.5ml CPT 91322 | not published | not published | $177.82 – $440.09 | 4 |
| Vaccine covid-19 moderna 6mos-11yrs 25mcg/0.25ml CPT 91321 | not published | not published | $161.77 – $400.37 | 4 |
| Vaccine covid-19 pfizer tris-sucrose >=12yrs 30mcg/0.3ml im CPT 91320 | not published | not published | $171.49 – $424.45 | 4 |
| Vaccine covid-19 pfizer tris-sucrose 5yrs-11yrs 10mcg/0.3ml im CPT 91319 | not published | not published | $96.56 – $238.99 | 4 |
| Vaccine covid-19 pfizer tris-sucrose 6mos-4yrs 3mcg/0.3ml im CPT 91318 | not published | not published | $72.11 – $178.46 | 4 |
| Vaccine dtap < 7 years im CPT 90700 | not published | not published | $96.33 – $96.33 | 1 |
| Vaccine dtap-hep b-ipv im CPT 90723 | not published | not published | $309.85 – $309.85 | 1 |
| Vaccine dtap-ipv 4-6 years im CPT 90696 | not published | not published | $415.37 – $415.37 | 1 |
| Vaccine dtap-ipv-hib-hepb im CPT 90697 | not published | not published | $1,018.73 – $1,018.73 | 1 |
| Vaccine dtap-ipv/hib im CPT 90698 | not published | not published | $367.50 – $367.50 | 1 |
| Vaccine haemophilus influenzae type b (hib) prp-omp 3 dose im CPT 90647 | not published | not published | $99.48 – $99.48 | 1 |
| Vaccine haemophilus influenzae type b (hib) prp-t 4 dose im CPT 90648 | not published | not published | $42.42 – $42.42 | 1 |
| Vaccine hepatitis a (hepa) adult im CPT 90632 | not published | not published | $79.38 – $194.96 | 4 |
| Vaccine hepatitis a (hepa) hepatitis b (hepb) adult im CPT 90636 | not published | not published | $352.09 – $352.09 | 1 |
| Vaccine hepatitis a (hepa) pediatric/adolescent 2 dose im CPT 90633 | not published | not published | $114.30 – $114.30 | 1 |
| Vaccine hepatitis a (hepa) pediatric/adolescent 3 dose im CPT 90634 | not published | not published | $79.25 – $79.25 | 1 |
| Vaccine hepatitis b (hepb) adolescent 2 dose im CPT 90743 | not published | not published | $82.67 – $204.60 | 4 |
| Vaccine hepatitis b (hepb) adult 3 dose im CPT 90746 | not published | not published | $77.42 – $191.61 | 4 |
| Vaccine hepatitis b (hepb) adult dosage 2 dose schedule im CPT 90739 | not published | not published | $195.32 – $458.21 | 4 |
| Vaccine hepatitis b (hepb) pediatric/adolescent 3 dose im CPT 90744 | not published | not published | $34.84 – $83.77 | 4 |
| Vaccine hpv types 6/11/16/18/31/33/45/52/58 nonvalent (9vhpv) 2 or 3 dose im CPT 90651 | not published | not published | $1,004.55 – $1,004.55 | 1 |
| Vaccine hpv types 6/11/16/18 quadrivalent (4vhpv) 3 dose im CPT 90649 | not published | not published | $286.21 – $286.21 | 1 |
| Vaccine influenza (iiv) preservative free antigen content im CPT 90662 | not published | not published | $91.84 – $227.30 | 4 |
| Vaccine influenza inactivated adjuvant im CPT 90653 | not published | not published | $91.84 – $227.30 | 4 |
| Vaccine influenza nos 0.5ml dose im CPT 90658 | not published | not published | $24.05 – $59.52 | 4 |
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.