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 |
|---|---|---|---|---|
| Chromosome count additional CPT 88285 | not published | not published | $20.18 – $51.94 | 7 |
| Chromosome karyotype study CPT 88280 | $55.00 | $100.00 | $25.10 – $64.60 | 7 |
| Chromosome study additional CPT 88289 | not published | not published | $25.82 – $66.45 | 7 |
| Chronic urticaria - sendout CPT 86343 | not published | not published | $9.34 – $24.05 | 7 |
| Chylomicron screen, bf - sendout CPT 82664 | $111.10 | $202.00 | $46.12 – $118.70 | 7 |
| Cidofovir injection HCPCS J0740 | not published | not published | $326.01 – $1,033.97 | 8 |
| Cilastatin sodium injection HCPCS J0743 | not published | not published | $7.80 – $19.60 | 5 |
| Ciliary transsleral therapy CPT 66710 | not published | not published | $1,763.69 – $7,791.00 | 6 |
| Ciltacabtagene car-pos t HCPCS Q2056 | not published | not published | $440,983.32 – $1,500,964.18 | 7 |
| Cinacalcet 30 mg tablet HCPCS J0604 | not published | not published | $2.69 – $2.69 | 1 |
| Cine/video x-rays CPT 76120 | not published | not published | $77.56 – $199.58 | 4 |
| Cine/video x-rays add-on CPT 76125 | not published | not published | $105.72 – $105.72 | 1 |
| Ciprofloxacin 400 mg/200 ml in 5 % dextrose intravenous piggyback HCPCS J0744 | not published | not published | $0.89 – $4.41 | 5 |
| Ciprofloxacin otic susp 6 mg HCPCS J7342 | not published | not published | $92.52 – $92.52 | 1 |
| Circum 28 days or older CPT 54161 | not published | not published | $1,550.71 – $7,791.00 | 6 |
| Circumcise/surg/28 days or < 54160 CPT 54160 | not published | not published | $517.28 – $7,791.00 | 6 |
| Circumcision (newborn) CPT 54150 | $94.60 | $172.00 | $1,550.71 – $7,791.00 | 6 |
| Cisplatin 1 mg/ml desensitization HCPCS J9060 | not published | not published | $2.91 – $7.33 | 5 |
| C-kit mutation liquid tumor - sendout CPT 81272 | $783.20 | $1,424.00 | $247.13 – $635.95 | 7 |
| Cladribine 10 mg/10 ml intravenous solution HCPCS J9065 | not published | not published | $6.14 – $30.69 | 8 |
| Clamp isol transpolr 5mmx6.5cm transpolar HCPCS C1733 | $8,873.40 | $16,133.46 | not published | 0 |
| Claviculectomy partial CPT 23120 | not published | not published | $2,427.27 – $8,770.00 | 6 |
| Claviculectomy total CPT 23125 | not published | not published | $2,427.27 – $8,770.00 | 6 |
| Clean out mastoid cavity CPT 69222 | not published | not published | $400.09 – $2,334.00 | 6 |
| Clearance of airways CPT 31720 | $121.55 | $221.00 | $162.44 – $2,334.00 | 6 |
| Clearance of tear duct CPT 68530 | not published | not published | $235.46 – $2,334.00 | 6 |
| C-lens fitg corneosclrl lens CPT 92313 | not published | not published | $98.70 – $253.99 | 4 |
| C-lens fitg tech aphakia 1 CPT 92315 | not published | not published | $98.70 – $253.99 | 4 |
| C-lens fitg tech aphakia ou CPT 92316 | not published | not published | $98.70 – $253.99 | 4 |
| C-lens fitg tech corneosclrl CPT 92317 | not published | not published | $27.71 – $71.30 | 4 |
| Clindamycin 600 mg/50 ml in 5 % dextrose intravenous piggyback HCPCS J0736 | not published | not published | $1.77 – $5.79 | 5 |
| Clip ligating vesolock lg HCPCS C1760 | $490.88 | $892.50 | not published | 0 |
| Clitoroplasty intersex state CPT 56805 | not published | not published | $2,401.40 – $7,791.00 | 6 |
| Cllr miami j sm HCPCS L0174 | not published | not published | $256.68 – $660.52 | 4 |
| Clofarabine 1 mg/ml intravenous solution HCPCS J9027 | not published | not published | $9.15 – $31.35 | 8 |
| Clonidine (pf) 1,000 mcg/10 ml (100 mcg/ml) epidural solution HCPCS J0735 | not published | not published | $17.82 – $45.57 | 5 |
| Close bronchial fistula 32815 CPT 32815 | not published | not published | $5,257.00 – $5,257.00 | 1 |
| Closed carpo/metacarpal disl thumb w/manip CPT 26641 | $492.25 | $895.00 | $182.99 – $2,334.00 | 6 |
| Closed carpo/metacarpal fx disl thumb w/manip CPT 26645 | not published | not published | $1,192.86 – $3,069.63 | 6 |
| Closed treatment of femoral fracture proximal end neck; wi CPT 27232 | not published | not published | $1,192.86 – $4,761.00 | 6 |
| Closed tx/acetabululm without manip 27220 CPT 27220 | not published | not published | $182.99 – $2,334.00 | 6 |
| Closed tx humerus fx with manip 23605 CPT 23605 | not published | not published | $1,192.86 – $7,791.00 | 6 |
| Closed tx humerus fx without manip 23600 CPT 23600 | not published | not published | $182.99 – $2,334.00 | 6 |
| Closed tx humerus fx w/manip 24505 CPT 24505 | $803.55 | $1,461.00 | $1,192.86 – $3,069.63 | 6 |
| Closed tx metatarsophalangeal jnt disl without anes CPT 28630 | $526.35 | $957.00 | $182.99 – $2,334.00 | 6 |
| Closed tx nose/jaw fx CPT 21345 | not published | not published | $1,151.01 – $4,761.00 | 6 |
| Closed tx orbit without manipulj CPT 21400 | not published | not published | $400.09 – $2,334.00 | 6 |
| Closed tx orbit w/manipulj CPT 21401 | not published | not published | $1,151.01 – $4,761.00 | 6 |
| Closed tx post hip arthroplasty disloc w/anes 27266 CPT 27266 | $3,069.00 | $5,580.00 | $1,192.86 – $4,761.00 | 6 |
| Closed tx septal&nose fx CPT 21337 | not published | not published | $2,459.51 – $6,329.15 | 6 |
| Closed tx sesamoid fx 28530 CPT 28530 | not published | not published | $182.99 – $2,334.00 | 6 |
| Closed tx/talus fracture without manip 28430 CPT 28430 | not published | not published | $182.99 – $2,334.00 | 6 |
| Closed tx vert fx w/manj CPT 22315 | not published | not published | $2,427.27 – $6,246.19 | 6 |
| Close lac/mouth vest/2.5 cm or < 40830 CPT 40830 | $481.80 | $876.00 | $175.70 – $2,334.00 | 6 |
| Close mastoid fistula CPT 69700 | not published | not published | $1,151.01 – $4,761.00 | 6 |
| Close median sternotomy separation 21750 CPT 21750 | not published | not published | $3,735.00 – $18,364.00 | 6 |
| Close tear duct opening CPT 68760 | not published | not published | $235.46 – $2,334.00 | 6 |
| Close tear duct opening CPT 68761 | not published | not published | $235.46 – $2,334.00 | 6 |
| Close tear system fistula CPT 68770 | not published | not published | $1,763.69 – $4,538.57 | 6 |
| Clostridium toxin a w/optic CPT 87803 | not published | not published | $12.00 – $30.88 | 7 |
| Clos txnose fx without stablz 21315 CPT 21315 | $4,488.55 | $8,161.00 | $1,151.01 – $4,761.00 | 6 |
| Closure enterostomy lg/sm intestine 44620 CPT 44620 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Closure enterostomy lg/sm intestine anast 44626 CPT 44626 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Closure enterostomy lg/sm intestine oth/thn 44625 CPT 44625 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Closure intestinal cutaneous fistula 44640 CPT 44640 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Closure laceration vestibule mouth > 2.5 cm cmplx CPT 40831 | not published | not published | $400.09 – $2,334.00 | 6 |
| Closure of eyelid by suture CPT 67875 | not published | not published | $739.52 – $4,761.00 | 6 |
| Closure of salivary fistula CPT 42600 | not published | not published | $2,459.51 – $6,329.15 | 6 |
| Closure of windpipe lesion 31820 CPT 31820 | not published | not published | $2,459.51 – $7,791.00 | 6 |
| Closure paravalvlr leak pq CPT 33999 | $23,443.20 | $42,624.00 | $465.35 – $3,030.00 | 6 |
| Clot factor fletcher fact CPT 85292 | not published | not published | $14.20 – $36.53 | 7 |
| Clot factor viii reltd antgn CPT 85244 | not published | not published | $15.32 – $39.41 | 7 |
| Clot factor wght kininogen CPT 85293 | not published | not published | $14.20 – $36.53 | 7 |
| Clot factor xii hageman CPT 85280 | $169.40 | $308.00 | $14.51 – $37.35 | 7 |
| Clot factor xiii fibrin scrn CPT 85291 | $15.95 | $29.00 | $6.83 – $17.58 | 7 |
| Clot factor xiii fibrin stab CPT 85290 | not published | not published | $12.26 – $31.54 | 7 |
| Clotting assay whole blood CPT 85396 | not published | not published | $20.93 – $30.47 | 2 |
| Clsd/shoulder dislo/manip/no anest 23650 CPT 23650 | $1,026.30 | $1,866.00 | $182.99 – $2,334.00 | 6 |
| Clsd tx bimalleol ank fx without manip 27808 CPT 27808 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx carpo/metacarpl disl thmb manip ea without anes CPT 26670 | $448.80 | $816.00 | $182.99 – $2,334.00 | 6 |
| Clsd tx clav dislc without manip 23520 CPT 23520 | not published | not published | $1,192.86 – $4,761.00 | 6 |
| Clsd tx clavicle dislocation without manip 23540 CPT 23540 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx clavicle fracture w/manip 23505 CPT 23505 | not published | not published | $1,192.86 – $3,069.63 | 6 |
| Clsd tx/clavicular fx without manip 23500 CPT 23500 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx coccygeal fracture 27200 CPT 27200 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx/dis phalan fx without manip/ea 26750 CPT 26750 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx dist fib fx w/manip 27788 CPT 27788 | $631.40 | $1,148.00 | $182.99 – $2,334.00 | 6 |
| Clsd tx/dis tib/wt bear no manip 27824 CPT 27824 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx elbow dislocation child 24640 CPT 24640 | $526.35 | $957.00 | $182.99 – $2,334.00 | 6 |
| Clsd tx/fem shaft fx/manipulation 27502 CPT 27502 | $2,118.05 | $3,851.00 | $1,192.86 – $4,761.00 | 6 |
| Clsd tx finger tendon w/wo perq pin 26432 CPT 26432 | not published | not published | $1,192.86 – $4,761.00 | 6 |
| Clsd tx fracture of radius 25500 CPT 25500 | $492.25 | $895.00 | $182.99 – $2,334.00 | 6 |
| Clsd tx/fx grt toe/phalanx/phalang 28490 CPT 28490 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx/fx/phalanx/phalang/manip 28515 CPT 28515 | $526.35 | $957.00 | $182.99 – $2,334.00 | 6 |
| Clsd tx fx radius/ulna dist without manip 25600 CPT 25600 | $391.05 | $711.00 | $182.99 – $2,334.00 | 6 |
| Clsd tx fx radius/ulna dist w/manip 25605 CPT 25605 | $3,069.00 | $5,580.00 | $1,192.86 – $3,069.63 | 6 |
| Clsd tx fx radius/ulna without manip 25560 CPT 25560 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx fx radius/ulna w/manip 25565 CPT 25565 | $3,092.10 | $5,622.00 | $1,192.86 – $3,069.63 | 6 |
| Clsd tx/grt hum tube fx without manip 23620 CPT 23620 | not published | not published | $182.99 – $2,334.00 | 6 |
| Clsd tx hip disloc without anes 27265 CPT 27265 | $1,306.80 | $2,376.00 | $182.99 – $2,334.00 | 6 |
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.