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 |
|---|---|---|---|---|
| Graft jckt xpress 2ml flowable scaffold-q4113-cost per sq cm HCPCS Q4113 | not published | not published | $5,438.20 – $5,438.20 | 1 |
| Graft nerve adv 3-4x70mm HCPCS C1762 | $9,272.26 | $16,858.65 | not published | 0 |
| Graft patch felt ptfe 2x2 HCPCS C1768 | $2,150.95 | $3,910.81 | not published | 0 |
| Graft primatrix xcr 6cm x6cm n-q4110-cost per sq cm HCPCS Q4110 | not published | not published | $71.95 – $237.56 | 7 |
| Graft puraplyam antimicrob 1.6-q4196-cost per sq cm HCPCS Q4196 | not published | not published | $92.32 – $287.74 | 7 |
| Graft repair of spine defect 63710 CPT 63710 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Graft sft tiss grafix amnio prime 3x4cm 12sqcm-q4133-cost per sq cm HCPCS Q4133 | not published | not published | $92.32 – $377.75 | 7 |
| Graft sft tiss theraskin lg 5.1x7.6cm meshed 39 sq cm-q4121-cost per sq cm HCPCS Q4121 | not published | not published | $56.97 – $237.56 | 7 |
| Graft wnd mtrx grfx core 1.5x2cm-q4132-cost per sq cm HCPCS Q4132 | not published | not published | $41.25 – $372.57 | 7 |
| Graft xenmtrx sft rect 15x20cm HCPCS C1781 | $770.66 | $1,401.20 | not published | 0 |
| Granisetron 1 mg tab HCPCS Q0166 | not published | not published | $140.48 – $140.48 | 1 |
| Granisetron hcl injection HCPCS J1626 | not published | not published | $0.24 – $0.63 | 5 |
| Granulocyte pheresis ea unit HCPCS P9050 | $2,124.65 | $3,863.00 | not published | 0 |
| Great toe-hand transfer CPT 26551 | not published | not published | $3,735.00 – $16,106.00 | 6 |
| Great toe with reduction 28495 CPT 28495 | $495.00 | $900.00 | $182.99 – $2,334.00 | 6 |
| Grfg autol fat lipo 25 cc/< CPT 15773 | not published | not published | $1,530.61 – $4,761.00 | 6 |
| Grfg autol fat lipo 50 cc/< CPT 15771 | not published | not published | $2,628.85 – $8,770.00 | 6 |
| Grfg autol fat lipo ea addl CPT 15772 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Grfg autol soft tiss dir exc CPT 15769 | not published | not published | $2,628.85 – $8,770.00 | 6 |
| Group behave couns 2-10 HCPCS G0473 | not published | not published | $27.80 – $71.53 | 4 |
| Group mnt 2 or more 30 mins HCPCS G0271 | $56.65 | $103.00 | $8.98 – $23.10 | 4 |
| Group train without patient HCPCS G0543 | not published | not published | $21.46 – $55.21 | 4 |
| Growth hormone antibody CPT 86277 | not published | not published | $11.80 – $30.38 | 7 |
| Growth hormone panel CPT 80428 | not published | not published | $50.02 – $128.73 | 7 |
| Growth hormone panel CPT 80430 | not published | not published | $97.00 – $249.61 | 7 |
| Growth stimulation gene 2 CPT 83006 | not published | not published | $44.51 – $145.91 | 7 |
| Grp adapt bhv tx by phy/qhp CPT 97158 | not published | not published | $27.80 – $71.53 | 4 |
| Grp adapt bhv tx by tech CPT 97154 | not published | not published | $27.80 – $71.53 | 4 |
| Gstrct prtl dstl w/roux-en-y rcnstj 43633 CPT 43633 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Gstr rstcv oth/thn v-band CPT 43843 | not published | not published | $3,735.00 – $16,106.00 | 3 |
| Gstr rstcv px shrt roux-en-y CPT 43846 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Gstr rstcv px sm int rcnstj CPT 43847 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Gstr rstcv px v-banded gstp CPT 43842 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Gstrst open wo constj tube CPT 43830 | not published | not published | $1,423.51 – $7,791.00 | 6 |
| G-tube reposition CPT 43761 | $575.85 | $1,047.00 | $185.35 – $2,334.00 | 6 |
| Gu dilat ureter/urethra s&i CPT 74485 | $254.10 | $462.00 | $219.33 – $3,990.50 | 4 |
| Guided cath fluid drainage 10030 CPT 10030 | $3,446.30 | $6,266.00 | $525.32 – $3,030.00 | 6 |
| Guide endoanchr sg-64 aaa 62cm HCPCS L8670 | $6,618.30 | $12,033.28 | not published | 0 |
| Guide wire threaded 1.4x150mm HCPCS C1769 | $770.57 | $1,401.03 | not published | 0 |
| Guide worley csg 9fx50cm std HCPCS C1892 | $70.81 | $128.75 | not published | 0 |
| Guid loc target vol rad tx CPT 77387 | $433.40 | $788.00 | $215.16 – $215.16 | 1 |
| Gum graft CPT 41870 | not published | not published | $1,151.01 – $4,761.00 | 6 |
| Gw stiffened micro access kit HCPCS C1894 | $262.75 | $477.73 | not published | 0 |
| Gynecomastia (males) 19300 CPT 19300 | not published | not published | $2,904.59 – $7,791.00 | 6 |
| Hair analysis HCPCS P2031 | not published | not published | $4.95 – $9.07 | 4 |
| Hair removal by electrolysis 17380 CPT 17380 | not published | not published | $548.27 – $2,334.00 | 6 |
| Hair trnspl 1-15 punch grfts CPT 15775 | not published | not published | $301.57 – $2,334.00 | 6 |
| Hair trnspl >15 punch grafts CPT 15776 | not published | not published | $301.57 – $2,334.00 | 6 |
| Hallus-valgus nt dyn pre ots HCPCS L3100 | not published | not published | $39.87 – $102.60 | 4 |
| Halo cervical into body jack HCPCS L0820 | not published | not published | $1,938.02 – $4,987.16 | 4 |
| Halo cervical into jckt vest HCPCS L0810 | not published | not published | $2,463.68 – $6,339.88 | 4 |
| Halo cerv into milwaukee typ HCPCS L0830 | not published | not published | $2,965.44 – $7,631.07 | 4 |
| Haloperidol decanoate 50 mg/ml intramuscular solution HCPCS J1631 | not published | not published | $5.07 – $15.11 | 5 |
| Haloperidol lactate 5 mg/ml injection solution HCPCS J1630 | not published | not published | $0.86 – $3.30 | 5 |
| Halo repl liner/interface HCPCS L0861 | not published | not published | $198.67 – $511.24 | 4 |
| Handle/convey/speciman/office-lab 99000 CPT 99000 | not published | not published | $5.77 – $5.77 | 1 |
| Hand orthosis metacarpal fracture orthosis prefa l3918 HCPCS L3918 | not published | not published | $88.58 – $227.95 | 4 |
| Hand restoration multiple fi HCPCS L6905 | not published | not published | $1,772.57 – $4,561.42 | 4 |
| Hand restoration no fingers HCPCS L6910 | not published | not published | $1,742.56 – $4,484.20 | 4 |
| Hand restoration replacmnt g HCPCS L6915 | not published | not published | $748.71 – $1,926.68 | 4 |
| Hand restorat thumb/1 finger HCPCS L6900 | not published | not published | $1,790.98 – $4,608.80 | 4 |
| Hand tendon/muscle transfer CPT 26494 | not published | not published | $2,427.27 – $8,770.00 | 6 |
| Hand tendon reconstruction CPT 26500 | not published | not published | $3,579.00 – $13,851.98 | 6 |
| Hand tendon reconstruction CPT 26502 | not published | not published | $2,427.27 – $8,770.00 | 6 |
| Hand X-ray CPT 73130 | $304.15 | $553.00 | $64.56 – $166.13 | 4 |
| Haptoglobin quantitative CPT 83010 | $98.45 | $179.00 | $9.44 – $24.28 | 7 |
| Harness chest/shlder saddle HCPCS L6672 | not published | not published | $202.07 – $520.00 | 4 |
| Harness figure of 8 dual con HCPCS L6676 | not published | not published | $115.36 – $296.87 | 4 |
| Harness figure of 8 sing con HCPCS L6675 | not published | not published | $110.26 – $283.75 | 4 |
| Harvest allogeneic stem cell CPT 38205 | not published | not published | $1,887.00 – $4,428.00 | 3 |
| Harvest auto stem cells CPT 38206 | not published | not published | $1,155.35 – $4,761.00 | 6 |
| Harvest cultured skin graft 15040 CPT 15040 | not published | not published | $1,530.61 – $4,761.00 | 6 |
| Harvest eye tissue alograft CPT 68371 | not published | not published | $1,763.69 – $7,791.00 | 6 |
| Harvest femoropopliteal vein 35572 CPT 35572 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Harvest stem cell concentrte CPT 38215 | not published | not published | $327.28 – $2,334.00 | 6 |
| Harvest vein for bypass 35500 CPT 35500 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Hast w/i&r phys/qhp CPT 94452 | not published | not published | $98.70 – $253.99 | 4 |
| Hast w/oxygen titrate CPT 94453 | not published | not published | $98.70 – $253.99 | 4 |
| Hba1/hba2 full gene sequence CPT 81259 | not published | not published | $450.00 – $1,158.00 | 7 |
| Hba1/hba2 gene dup/del vrnts CPT 81269 | not published | not published | $151.80 – $390.63 | 7 |
| Hba1/hba2 gene fam vrnt CPT 81258 | not published | not published | $281.44 – $724.23 | 7 |
| Hbb full gene sequence CPT 81364 | not published | not published | $243.44 – $626.44 | 7 |
| Hbb gene com variants CPT 81361 | not published | not published | $131.11 – $337.38 | 7 |
| Hbb gene dup/del variants CPT 81363 | not published | not published | $151.80 – $390.63 | 7 |
| Hbb gene known fam variant CPT 81362 | not published | not published | $281.44 – $724.23 | 7 |
| Hb glycosylated a1c home dev CPT 83037 | not published | not published | $7.28 – $18.74 | 7 |
| Hbot, full body chamber, 30m HCPCS G0277 | $365.75 | $665.00 | not published | 0 |
| Hc fl sm bowel enteroclss tube w kub double contrast CPT 74251 | not published | not published | $130.12 – $334.84 | 4 |
| Hcg free betachain test CPT 84704 | $28.05 | $51.00 | $11.47 – $29.51 | 7 |
| Hcg qualitative CPT 84703 | $75.90 | $138.00 | $5.64 – $14.51 | 7 |
| Hcg quantitative CPT 84702 | $130.90 | $238.00 | $11.29 – $29.05 | 7 |
| Hc i-131 sodium iodide cap dx per mci HCPCS A9528 | not published | not published | $257.14 – $257.14 | 1 |
| Hc metata joint dislocation anes CPT 28635 | $3,343.45 | $6,079.00 | $1,192.86 – $4,761.00 | 6 |
| Hc mohs micrographic h/n/h/f/g 1st stage 5 blocks CPT 17311 | not published | not published | $548.27 – $2,334.00 | 6 |
| Hc mohs micrographic h/n/h/f/g each addl stage CPT 17312 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Hc mohs trunk/arm/leg 1st stage 5 blocks CPT 17313 | not published | not published | $548.27 – $2,334.00 | 6 |
| Hc mohs trunk/arm/leg ea addl block any stage CPT 17315 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Hc mohs trunk/arm/leg ea stage after 1st stage CPT 17314 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Hc nm cardiac blood pool planar 1 stdy wal motn eject fract CPT 78481 | not published | not published | $402.79 – $1,036.52 | 4 |
| Hc nm fusion spect CT unlisted CPT 78999 | not published | not published | $296.56 – $763.16 | 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.