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 |
|---|---|---|---|---|
| X-ray colon abdominal radiograph(s) & delayed images single contrast study CPT 74270 | $276.65 | $503.00 | $130.12 – $334.84 | 4 |
| X-ray colon abdominal radiograph(s) & delayed images with glucagon double contrast study CPT 74280 | $276.65 | $503.00 | $130.12 – $334.84 | 4 |
| X-ray elbow 2 views (both sides) CPT 73070 | $304.15 | $553.00 | $63.69 – $166.13 | 4 |
| X-ray elbow >= 3 views (both sides) CPT 73080 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| Xray endovasc thor ao repr CPT 75956 | $709.50 | $1,290.00 | $1,167.09 – $1,167.09 | 1 |
| Xray endovasc thor ao repr CPT 75957 | $709.50 | $1,290.00 | $1,000.51 – $1,000.51 | 1 |
| X-ray esophogram chest radiograph(s) & delayed images single contrast study CPT 74220 | $276.65 | $503.00 | $130.12 – $334.84 | 4 |
| X-ray exam entire spi 4/5 vw CPT 72083 | not published | not published | $77.56 – $199.58 | 4 |
| X-ray exam entire spi 6/> vw CPT 72084 | not published | not published | $77.56 – $199.58 | 4 |
| X-ray exam of arm infant CPT 73092 | $304.15 | $553.00 | $62.49 – $199.58 | 4 |
| X-ray exam of eye sockets CPT 70200 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray exam of femur 1 CPT 73551 | not published | not published | $63.69 – $166.13 | 4 |
| X-ray exam of jaw joint CPT 70328 | not published | not published | $64.56 – $166.13 | 4 |
| X-ray exam of jaw joint CPT 70332 | not published | not published | $165.86 – $455.49 | 4 |
| X-ray exam of mastoids CPT 70120 | not published | not published | $77.56 – $199.58 | 4 |
| X-ray exam of middle ear CPT 70134 | not published | not published | $111.20 – $1,043.10 | 4 |
| X-ray exam of penis CPT 74445 | not published | not published | $77.56 – $199.58 | 4 |
| X-ray exam of perineum CPT 74775 | not published | not published | $177.00 – $455.49 | 4 |
| X-ray exam of salivary gland CPT 70380 | not published | not published | $64.56 – $166.13 | 4 |
| X-ray exam of sinuses CPT 70210 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray exam of tear duct CPT 70170 | not published | not published | $121.41 – $455.49 | 4 |
| X-ray exam of teeth CPT 70300 | not published | not published | $29.21 – $166.13 | 4 |
| X-ray exam of teeth CPT 70310 | not published | not published | $94.58 – $455.49 | 4 |
| X-ray exam si joints CPT 72200 | $304.15 | $553.00 | $64.88 – $199.58 | 4 |
| X-ray exam thorac spine4/>vw CPT 72074 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray eye detection foreign body (both sides) CPT 70030 | $276.65 | $503.00 | $63.69 – $166.13 | 4 |
| X-ray facial bones complete > 3 views CPT 70150 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray fallopian tube CPT 74742 | not published | not published | $181.48 – $181.48 | 1 |
| X-ray femur >=2 views (both sides) CPT 73552 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray finger(s) >= 2 views (both sides) CPT 73140 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray foot 2 views (both sides) CPT 73620 | $304.15 | $553.00 | $60.11 – $166.13 | 4 |
| X-ray forearm 2 views (both sides) CPT 73090 | $304.15 | $553.00 | $56.56 – $166.13 | 4 |
| X-ray hand 2 views (both sides) CPT 73120 | $304.15 | $553.00 | $57.74 – $199.58 | 4 |
| X-ray head for orthodontia CPT 70350 | not published | not published | $31.60 – $166.13 | 4 |
| X-ray heel/calcaneus > 2 views (both sides) CPT 73650 | $304.15 | $553.00 | $62.49 – $166.13 | 4 |
| X-ray hip uni w/wo pelvis min 4 views CPT 73503 | not published | not published | $77.56 – $199.58 | 4 |
| X-ray hip with pelvis when performed bilateral 2 views CPT 73521 | $272.25 | $495.00 | $77.56 – $199.58 | 4 |
| X-ray hip with pelvis when performed bilateral 3-4 views CPT 73522 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray hip with pelvis when performed bilateral >= 5 views CPT 73523 | $336.05 | $611.00 | $77.56 – $199.58 | 4 |
| X-ray hip with pelvis when performed unilateral 1 view left CPT 73501 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray humerus >= 2 views left CPT 73060 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray joint survey 1 view CPT 77077 | $304.15 | $553.00 | $69.62 – $199.58 | 4 |
| X-ray knee 1-2 views (both sides) CPT 73560 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray knee 3 views (both sides) CPT 73562 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray knee ap standing bilateral CPT 73565 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray lower extremities infant > 2 views (both sides) CPT 73592 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray l/s-spine bend vw only 2-3 vw CPT 72120 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray lumbosacral spine >= 4 views CPT 72110 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray lumbosacral spine complete including bending views >= 6 views CPT 72114 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray male genital tract CPT 74440 | not published | not published | $177.00 – $455.49 | 4 |
| X-ray mandible complete > 4 views CPT 70110 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray mandible ltd <4 views CPT 70100 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray nasal bones complete > 3 views CPT 70160 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray neck soft tissue CPT 70360 | $276.65 | $503.00 | $64.56 – $166.13 | 4 |
| X-ray nose to rectum for foreign body child CPT 76010 | $276.65 | $503.00 | $55.37 – $166.13 | 4 |
| X-ray of mammary ducts CPT 77054 | $443.30 | $806.00 | $177.00 – $455.49 | 4 |
| X-ray optic foramina CPT 70190 | not published | not published | $64.56 – $166.13 | 4 |
| X-ray pelvis 1-2 views CPT 72170 | $304.15 | $553.00 | $75.56 – $199.58 | 4 |
| X-ray pelvis complete > 3 views CPT 72190 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| Xray place dist ext thor ao CPT 75959 | $3,177.35 | $5,777.00 | $579.14 – $579.14 | 1 |
| Xray place prox ext thor ao CPT 75958 | not published | not published | $664.33 – $664.33 | 1 |
| X-ray retrograde pyelogram with or without kidney ureter bladder w/supervision & interpretation CPT 74420 | $275.00 | $500.00 | $258.81 – $665.99 | 4 |
| X-ray ribs 2 views left CPT 71100 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray ribs 3 views bilateral CPT 71110 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray ribs w/posterior anterior chest 3 views left CPT 71101 | $304.15 | $553.00 | $74.37 – $199.58 | 4 |
| X-ray ribs w/posterior anterior chest > 4 views bilateral CPT 71111 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray sacroiliac joints >= 3 views CPT 72202 | $304.15 | $553.00 | $76.74 – $199.58 | 4 |
| X-ray sacrum/coccyx >= 2 views CPT 72220 | $304.15 | $553.00 | $63.69 – $166.13 | 4 |
| X-ray scapula complete (both sides) CPT 73010 | $304.15 | $553.00 | $68.42 – $199.58 | 4 |
| X-ray sella turcica CPT 70240 | not published | not published | $64.56 – $166.13 | 4 |
| X-ray shoulder 1 view (both sides) CPT 73020 | $304.15 | $553.00 | $49.43 – $166.13 | 4 |
| X-ray sinuses paranasal complete > 3 views CPT 70220 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray sinus tract/fistula/abscess CPT 76080 | $932.25 | $1,695.00 | $94.58 – $1,043.10 | 4 |
| X-ray skull < 4 views CPT 70250 | $304.15 | $553.00 | $76.74 – $199.58 | 4 |
| X-ray skull > 4 views complete CPT 70260 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray slg plne bdy sect without urogr CPT 76100 | not published | not published | $77.56 – $199.58 | 4 |
| X-ray small bowel multi serial images abdominal radiographs(s)&delayed images single contrast study CPT 74250 | $276.65 | $503.00 | $130.12 – $334.84 | 4 |
| X-ray small intestine follow-through study CPT 74248 | $180.40 | $328.00 | $155.12 – $155.12 | 1 |
| X-ray spine single view CPT 72020 | $304.15 | $553.00 | $47.04 – $166.13 | 4 |
| X-ray sternoclavicular joint(s) > 3 views CPT 71130 | not published | not published | $64.56 – $166.13 | 4 |
| X-ray sternum > 2 views CPT 71120 | $304.15 | $553.00 | $63.69 – $166.13 | 4 |
| X-ray surgical specimen CPT 76098 | $854.70 | $1,554.00 | $28.03 – $1,043.10 | 4 |
| X-ray swallowing function w/ciner/videoradiography neck radiographs(s)&delayed images contrast study CPT 74230 | $276.65 | $503.00 | $130.12 – $334.84 | 4 |
| X-ray temporomandibular joint open/closed mouth bilateral CPT 70330 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray thoracic spine 2 views CPT 72070 | $304.15 | $553.00 | $74.37 – $199.58 | 4 |
| X-ray thoracic spine 3 views CPT 72072 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray thoracolumbar spine >=2 views CPT 72080 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray thoracolumbar spine including skull cervical & sacral spine 1 view CPT 72081 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray thoracolumbar spine including skull cervical & sacral spine 2-3 views CPT 72082 | $304.15 | $553.00 | $77.56 – $199.58 | 4 |
| X-ray tibia/fibula 2 views (both sides) CPT 73590 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray toe(s) > 2 views (both sides) CPT 73660 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray upper gastrointestinal tract scout abdominal radiographs delayed images double contrast CPT 74246 | $276.65 | $503.00 | $130.12 – $334.84 | 4 |
| X-ray upper gastrointestinal tract scout abdominal radiographs delayed images single contrast study CPT 74240 | $276.65 | $503.00 | $130.12 – $334.84 | 4 |
| X-ray wrist 2 views (both sides) CPT 73100 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| X-ray xm phrnx&/crv esoph c+ CPT 74210 | $276.65 | $503.00 | $130.12 – $334.84 | 4 |
| Xwrap 1 sq cm HCPCS Q4204 | not published | not published | $92.32 – $9,314.68 | 6 |
| Xylose absorption test blood &/or urine CPT 84620 | not published | not published | $9.68 – $24.92 | 7 |
| Xyntha inj HCPCS J7185 | not published | not published | $1.03 – $4.09 | 8 |
| Yersinia antibody CPT 86793 | not published | not published | $9.89 – $25.46 | 7 |
| Yttrium y-90 ibritumomab ther HCPCS A9543 | $63,895.15 | $116,173.00 | $42,618.41 – $154,704.84 | 5 |
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.