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 |
|---|---|---|---|---|
| Lso full corset HCPCS L0976 | not published | not published | $137.81 – $354.64 | 4 |
| Lso r post pnl sj-t9 pre cst HCPCS L0630 | not published | not published | $149.29 – $384.17 | 4 |
| Lso sag-coronal panel custom HCPCS L0638 | not published | not published | $1,215.68 – $3,128.36 | 4 |
| Lso sag-co shell pnl pre ots HCPCS L0651 | not published | not published | $587.48 – $1,511.79 | 4 |
| Lso sag ctr rigi pos pre ots HCPCS L0643 | not published | not published | $80.10 – $206.12 | 4 |
| Lso sagit rigid panel prefab HCPCS L0635 | not published | not published | $921.02 – $2,370.08 | 4 |
| Lso sagittal rigid panel cus HCPCS L0636 | not published | not published | $1,249.66 – $3,215.80 | 4 |
| Lso sc r pos/lat pnl pre cst HCPCS L0633 | not published | not published | $264.31 – $680.15 | 4 |
| Lso sc r pos/lat pnl pre ots HCPCS L0649 | not published | not published | $141.83 – $364.98 | 4 |
| Lso s/c shell/panel custom HCPCS L0640 | not published | not published | $964.48 – $2,481.92 | 4 |
| Lso s/c shell/panel prefab HCPCS L0639 | not published | not published | $1,194.10 – $3,072.81 | 4 |
| L/s ratio fetal lung CPT 83661 | not published | not published | $16.49 – $42.44 | 7 |
| Lumbar bolster pad HCPCS L1030 | not published | not published | $72.17 – $185.72 | 4 |
| Lumbar derotation pad HCPCS L1240 | not published | not published | $83.83 – $215.72 | 4 |
| Lumbar diskogram s&i CPT 72295 | $3,359.40 | $6,108.00 | $183.68 – $3,727.72 | 4 |
| Lumbar or lumbar rib pad HCPCS L1040 | not published | not published | $81.72 – $210.29 | 4 |
| Lumbar sling HCPCS L1090 | not published | not published | $92.74 – $238.66 | 4 |
| Lumbar Spinal Fusion (single level) CPT 22612 | not published | not published | $7,609.00 – $33,471.73 | 6 |
| Lumizyme injection HCPCS J0221 | not published | not published | $158.35 – $548.97 | 8 |
| Lung function test (mbc/mvv) CPT 94200 | $369.60 | $672.00 | $43.76 – $112.62 | 4 |
| Lung Function Test (Spirometry) CPT 94010 | $172.15 | $313.00 | $160.18 – $412.19 | 4 |
| Lung perfusion imaging CPT 78580 | $1,936.00 | $3,520.00 | $296.56 – $763.16 | 4 |
| Lung transplant double CPT 32853 | not published | not published | $8,923.00 – $8,923.00 | 1 |
| Lung transplant single CPT 32851 | not published | not published | $8,923.00 – $8,923.00 | 1 |
| Lung transplant with bypass CPT 32852 | not published | not published | $8,923.00 – $8,923.00 | 1 |
| Lung transplant with bypass CPT 32854 | not published | not published | $8,923.00 – $8,923.00 | 1 |
| Lung volume reduction 32491 CPT 32491 | not published | not published | $7,609.00 – $7,609.00 | 1 |
| Lurbinectedin 4 mg intravenous solution HCPCS J9223 | not published | not published | $161.96 – $557.85 | 8 |
| Luspatercept-aamt 25 mg subcutaneous solution HCPCS J0896 | not published | not published | $32.64 – $112.38 | 8 |
| Lutetium lu 177 dotatat ther HCPCS A9513 | not published | not published | $262.66 – $806.54 | 5 |
| Lutetium lu 177 vipivotide HCPCS A9607 | not published | not published | $200.49 – $656.70 | 5 |
| Lvad shower bag heartmate HCPCS Q0501 | not published | not published | $471.63 – $1,213.66 | 4 |
| Lw ntsty Ultrasound stimj bone healg CPT 20979 | not published | not published | $21.46 – $2,334.00 | 6 |
| Lwr ext dynamic prosth pylon HCPCS L5985 | not published | not published | $260.80 – $671.12 | 4 |
| Lyme dis dna dir probe CPT 87475 | not published | not published | $15.04 – $38.70 | 7 |
| Lymphadenect/stage/pelv/paraaortic 38562 CPT 38562 | not published | not published | $5,257.00 – $18,364.00 | 6 |
| Lymphatics/lymph node imaging CPT 78195 | $1,936.00 | $3,520.00 | $402.79 – $1,036.52 | 4 |
| Lymphocyte culture mixed CPT 86821 | not published | not published | $27.42 – $70.56 | 7 |
| Lymphocyte transformation mitogen CPT 86353 | not published | not published | $36.77 – $94.63 | 7 |
| Lymphocytotoxicity assay CPT 86805 | not published | not published | $105.82 – $365.75 | 7 |
| Lymphocytotoxicity assay CPT 86806 | not published | not published | $35.69 – $91.85 | 7 |
| Lymph vessel x-ray arm/leg CPT 75801 | not published | not published | $465.35 – $1,197.51 | 4 |
| Lymph vessel x-ray arms/legs CPT 75803 | not published | not published | $684.20 – $3,005.03 | 4 |
| Lymph vessel x-ray trunk CPT 75805 | not published | not published | $760.95 – $6,027.57 | 4 |
| Lymph vessel x-ray trunk CPT 75807 | not published | not published | $734.95 – $6,027.57 | 4 |
| Lysis intranasal synechia 30560 CPT 30560 | not published | not published | $400.09 – $2,334.00 | 6 |
| Lysis of labial adhesions CPT 56441 | not published | not published | $2,401.40 – $7,791.00 | 6 |
| Lysis penil circumic lesion CPT 54162 | not published | not published | $1,550.71 – $7,791.00 | 6 |
| Lyumjev for insulin pump use HCPCS J1813 | not published | not published | $16.76 – $42.14 | 5 |
| Macro exam dissect molec study ea CPT 88387 | not published | not published | $7.22 – $13.02 | 2 |
| Macroscopic exam arthropod CPT 87168 | $10.45 | $19.00 | $3.20 – $8.24 | 7 |
| Macroscopic exam parasite CPT 87169 | $58.85 | $107.00 | $3.23 – $8.32 | 7 |
| Magnesium CPT 83735 | $116.05 | $211.00 | $5.02 – $12.93 | 7 |
| Magnesium sulfate 2 gram/50 ml (4 %) in water intravenous piggyback HCPCS J3475 | not published | not published | $0.53 – $1.34 | 5 |
| Magnetic image bone marrow CPT 77084 | not published | not published | $177.00 – $455.49 | 4 |
| Makena, 10 mg HCPCS J1726 | not published | not published | $37.62 – $37.62 | 1 |
| Malaria antibody CPT 86750 | not published | not published | $9.89 – $25.46 | 7 |
| Male sling procedure CPT 53440 | not published | not published | $7,609.00 – $27,583.00 | 6 |
| Management of liver hemorrhage 47361 CPT 47361 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Manipulate finger w/anesth CPT 26340 | not published | not published | $1,192.86 – $3,069.63 | 6 |
| Manipulate wrist w/anesthes CPT 25259 | not published | not published | $1,192.86 – $4,761.00 | 6 |
| Manipulation chest wall demonstration/evaluation subsequent CPT 94668 | $91.30 | $166.00 | $98.70 – $253.99 | 4 |
| Manipulation chest wall initial demonstration/evaluation CPT 94667 | $118.25 | $215.00 | $98.70 – $253.99 | 4 |
| Manipulation of hip joint CPT 27275 | not published | not published | $1,192.86 – $4,761.00 | 6 |
| Manipulation of spine CPT 22505 | not published | not published | $1,192.86 – $4,761.00 | 6 |
| Manipulat palm cord post inj CPT 26341 | not published | not published | $182.99 – $2,334.00 | 6 |
| Mannitol 12.5 gm/50 ml inj HCPCS J2150 | not published | not published | $2.49 – $6.91 | 5 |
| Mannitol for inhaler HCPCS J7665 | not published | not published | $3.22 – $3.22 | 1 |
| Man's shoe oxford brace HCPCS L3225 | not published | not published | $68.02 – $175.05 | 4 |
| Manual diff wbc count b-coat CPT 85009 | not published | not published | $3.80 – $9.79 | 7 |
| Mapping io sentinel lymph node CPT 38900 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Map tachycard site(s) CPT 93609 | $4,856.50 | $8,830.00 | $1,887.00 – $2,334.00 | 2 |
| Margetuximab-cmkb 25 mg/ml intravenous solution HCPCS J9353 | not published | not published | $42.33 – $134.49 | 8 |
| Marker biop eviva buckle ss HCPCS A4648 | $235.90 | $428.91 | not published | 0 |
| Marker lymphatic sentimag magtrace 10 vial HCPCS A9697 | not published | not published | $940.50 – $3,098.09 | 5 |
| Marsupialization liver lesion 47300 CPT 47300 | not published | not published | $3,735.00 – $3,735.00 | 1 |
| Mastectomy form HCPCS L8020 | not published | not published | $208.80 – $537.31 | 4 |
| Mastectomy partial CPT 19301 | not published | not published | $2,904.59 – $7,791.00 | 6 |
| Mast mod rad CPT 19307 | not published | not published | $4,925.89 – $16,106.00 | 6 |
| Mastoidectomy CPT 69501 | not published | not published | $4,391.52 – $16,106.00 | 6 |
| Mastoidectomy complete 69502 CPT 69502 | not published | not published | $4,391.52 – $11,300.84 | 6 |
| Mastoids complete CPT 70130 | not published | not published | $77.56 – $199.58 | 4 |
| Mastoid surgery revision CPT 69603 | not published | not published | $4,391.52 – $16,106.00 | 6 |
| Mastopexy CPT 19316 | not published | not published | $4,925.89 – $12,675.95 | 6 |
| Mast radical CPT 19305 | not published | not published | $6,019.00 – $6,019.00 | 1 |
| Mast rad urban type CPT 19306 | not published | not published | $6,019.00 – $6,019.00 | 1 |
| Mast simple complete CPT 19303 | not published | not published | $4,925.89 – $12,675.95 | 6 |
| Matrion 1 sq cm HCPCS Q4201 | not published | not published | $92.32 – $237.56 | 7 |
| Matrix bone cryomatrix 2.0ml HCPCS Q4162 | not published | not published | $6,987.77 – $6,987.77 | 1 |
| Matrix tissue 15x10cm gentrix extra-gynecological clgn strl-cost per sq cm HCPCS Q4166 | not published | not published | $23.65 – $237.56 | 7 |
| M.avium-intra dna amp prob CPT 87561 | $80.85 | $147.00 | $26.32 – $67.72 | 7 |
| M.avium-intra dna dir prob CPT 87560 | not published | not published | $20.47 – $52.67 | 7 |
| M.avium-intra dna quant CPT 87562 | not published | not published | $32.13 – $82.68 | 7 |
| Maxillofacial fixation CPT 21100 | not published | not published | $4,391.52 – $16,106.00 | 6 |
| Mayo a1app alpha 1 antitrypsin phenotype CPT 82104 | $117.70 | $214.00 | $10.84 – $27.91 | 7 |
| Mayo aathr protein s free CPT 85306 | $124.30 | $226.00 | $11.49 – $29.57 | 7 |
| Mayo activated protein c resistance assay CPT 85307 | $94.05 | $171.00 | $11.49 – $29.57 | 7 |
| Mayo adalimumab (humira) therapeutic drug level CPT 80145 | $63.80 | $116.00 | $28.93 – $74.44 | 7 |
| Mayo alcohol biomarkers definitive assay 1 or 2 phosphatidylethanol confirmation CPT 80321 | $194.15 | $353.00 | not published | 0 |
| Mayo alcohol definitive assay volatile screen CPT 80320 | $194.70 | $354.00 | $35.06 – $35.06 | 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.