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 |
|---|---|---|---|---|
| Assay of silica CPT 84285 | not published | not published | $18.91 – $48.66 | 7 |
| Assay of somatostatin CPT 84307 | not published | not published | $13.71 – $35.28 | 7 |
| Assay of thiocyanate CPT 84430 | not published | not published | $8.72 – $22.45 | 7 |
| Assay of troponin qual CPT 84512 | not published | not published | $7.57 – $19.47 | 7 |
| Assay of tyrosine CPT 84510 | not published | not published | $7.97 – $20.52 | 7 |
| Assay of urine sulfate CPT 84392 | not published | not published | $4.12 – $10.60 | 7 |
| Assay of urine urobilinogen CPT 84580 | not published | not published | $7.16 – $18.43 | 7 |
| Assay of urine urobilinogen CPT 84583 | not published | not published | $4.54 – $11.68 | 7 |
| Assay phosphatidylglycerol CPT 84081 | not published | not published | $12.39 – $31.88 | 7 |
| Assay phosphohexose enzymes CPT 84087 | not published | not published | $8.05 – $20.71 | 7 |
| Assay rbc glutathione CPT 82979 | not published | not published | $7.08 – $18.22 | 7 |
| Assay toxin or antitoxin CPT 87230 | $44.00 | $80.00 | $14.80 – $38.10 | 7 |
| Assess aphasia/interp/rpt/per hr 96105 CPT 96105 | not published | not published | $70.86 – $182.35 | 4 |
| Assess care plan pt w/cog impair 99483 CPT 99483 | $424.05 | $771.00 | $75.36 – $193.93 | 4 |
| Assess cyst contrast inject CPT 49424 | $337.15 | $613.00 | $1,887.00 – $5,512.00 | 3 |
| Assessment leukocyte fecal qualitative/semiquantitative CPT 89055 | not published | not published | $3.20 – $8.24 | 7 |
| Asses tinnit/pitch/loud/match/mask 92625 CPT 92625 | not published | not published | $95.45 – $245.63 | 4 |
| Assist-bilat spinal disk surgery add-on 63035 CPT 63035 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Assistive tech assessment, ot CPT 97755 | not published | not published | $27.61 – $71.04 | 4 |
| Assist oocyte fertilization CPT 89280 | not published | not published | $597.68 – $1,538.03 | 5 |
| Assist oocyte fertilization CPT 89281 | not published | not published | $126.39 – $325.23 | 5 |
| Ast/sgot CPT 84450 | $21.45 | $39.00 | $3.88 – $10.00 | 7 |
| Atezolizumab 60 mg/ml intravenous solution (wrapper) HCPCS J9022 | not published | not published | $72.41 – $240.17 | 8 |
| Athrectomy fem/pop/unilateral 37225 CPT 37225 | $13,229.15 | $24,053.00 | $7,609.00 – $27,583.00 | 3 |
| Athrectomy tib/pero/unilat/ini ves 37229 CPT 37229 | $12,584.00 | $22,880.00 | $8,923.00 – $27,583.00 | 3 |
| Atomic absorption CPT 82190 | not published | not published | $11.92 – $30.69 | 7 |
| Atropine 0.1 mg/ml injection syringe HCPCS J0461 | not published | not published | $0.11 – $0.30 | 5 |
| Attach bladder/urethra comp 51841 CPT 51841 | not published | not published | $3,735.00 – $7,791.00 | 3 |
| Attach bladder/urethra simple 51840 CPT 51840 | not published | not published | $3,710.98 – $9,549.58 | 6 |
| Attach ocular implant CPT 65140 | not published | not published | $2,916.44 – $8,770.00 | 6 |
| Aud brainstem implt programg CPT 92640 | not published | not published | $95.45 – $245.63 | 4 |
| Audiometry air + bone CPT 92553 | not published | not published | $95.45 – $245.63 | 4 |
| Auditory function 60 min CPT 92620 | not published | not published | $95.45 – $245.63 | 4 |
| Augmentation cheek bone CPT 21270 | not published | not published | $4,391.52 – $16,106.00 | 6 |
| Augmentation lower jaw bone CPT 21125 | not published | not published | $4,391.52 – $11,300.84 | 6 |
| Augmentation lower jaw bone CPT 21127 | not published | not published | $4,391.52 – $16,106.00 | 6 |
| Augmentation of facial bones CPT 21208 | not published | not published | $4,391.52 – $16,106.00 | 6 |
| Augumentation percutaneous vertebral inc cavity creation ea addl thoracic/lumbar vertebral body CPT 22515 | $6,790.30 | $12,346.00 | $1,887.00 – $5,512.00 | 3 |
| Augumentation percutaneous vertebral including cavity creation 1 vertebral body thoracic CPT 22513 | $7,004.80 | $12,736.00 | $5,382.89 – $18,364.00 | 6 |
| Autgrft implnt knee w/scope CPT 29866 | not published | not published | $5,382.89 – $18,364.00 | 6 |
| Autochondrocyte implant knee CPT 27412 | not published | not published | $5,382.89 – $18,364.00 | 6 |
| Autoimmune rheumatoid arthr anl 12 mrk ia CPT 81490 | not published | not published | $630.49 – $1,622.45 | 7 |
| Autologous blood op salvage CPT 86891 | not published | not published | $192.13 – $1,538.03 | 5 |
| Autologous blood process CPT 86890 | not published | not published | $126.39 – $325.23 | 5 |
| Autolog prp not diab ulcer HCPCS G0460 | not published | not published | $1,530.61 – $3,938.76 | 4 |
| Automated diff wbc count CPT 85004 | not published | not published | $4.85 – $12.49 | 7 |
| Autonomic nrv adrenrg inervj CPT 95922 | not published | not published | $98.70 – $253.99 | 4 |
| Autonomic nrv parasym inervj CPT 95921 | not published | not published | $95.45 – $245.63 | 4 |
| Autonomic nrv syst funj test CPT 95923 | not published | not published | $98.70 – $253.99 | 4 |
| Avelumab 20 mg/ml intravenous solution HCPCS J9023 | not published | not published | $81.48 – $263.95 | 8 |
| Av fistula revision CPT 36833 | $4,413.20 | $8,024.00 | $4,127.91 – $18,364.00 | 6 |
| Av fuse uppr arm basilic CPT 36819 | not published | not published | $4,127.91 – $18,364.00 | 6 |
| Av fuse uppr arm cephalic CPT 36818 | not published | not published | $4,127.91 – $18,364.00 | 6 |
| Av fusion direct any site CPT 36821 | not published | not published | $2,342.32 – $8,770.00 | 6 |
| Av fusion/forearm vein 36820 CPT 36820 | not published | not published | $4,127.91 – $18,364.00 | 6 |
| Avul nail plate addl CPT 11732 | $244.20 | $444.00 | $1,887.00 – $5,512.00 | 3 |
| Avulsion nail plate partial/complete simple single nail plate CPT 11730 | $275.55 | $501.00 | $148.84 – $2,334.00 | 6 |
| Axicabtagene ciloleucel car+ HCPCS Q2041 | not published | not published | $421,875.67 – $1,332,710.45 | 7 |
| Axillary lymphadenect/superficial 38740 CPT 38740 | not published | not published | $4,484.77 – $18,364.00 | 6 |
| Azacitidine injection HCPCS J9025 | not published | not published | $0.31 – $0.79 | 5 |
| Azathioprine 50 mg tablet HCPCS J7500 | not published | not published | $1.11 – $4.07 | 5 |
| Azathioprine parenteral HCPCS J7501 | not published | not published | $191.07 – $623.37 | 5 |
| Azithromycin 500 mg intravenous solution HCPCS J0456 | not published | not published | $2.31 – $5.79 | 5 |
| Aztreonam 1 gram solution for injection HCPCS J0457 | not published | not published | $2.24 – $5.64 | 5 |
| Baclofen 2,000 mcg/ml intrathecal solution (wrapper) HCPCS J0475 | not published | not published | $139.58 – $473.29 | 8 |
| Baclofen 50 mcg/ml intrathecal solution (wrapper) HCPCS J0476 | not published | not published | $44.10 – $127.69 | 5 |
| Baclofen eval charges CPT 97750 | $75.90 | $138.00 | $24.55 – $63.17 | 4 |
| Bacterial meningitis antigen CPT 86403 | not published | not published | $8.66 – $22.27 | 7 |
| Bacterial vaginosis pcr CPT 87801 | $162.25 | $295.00 | $52.65 – $135.49 | 7 |
| Bactericidal level serum CPT 87197 | not published | not published | $11.26 – $28.99 | 7 |
| #bac vag cand-c. albicans naa CPT 87481 | not published | not published | $26.32 – $67.72 | 7 |
| Balloon dilate urtrl strix CPT 50706 | $1,269.40 | $2,308.00 | $1,887.00 – $5,512.00 | 3 |
| Bartholin gland cyst/marsupializat 56440 CPT 56440 | not published | not published | $2,401.40 – $7,791.00 | 6 |
| Bartonella dna pcr-sendout CPT 87471 | $80.85 | $147.00 | $26.32 – $67.72 | 7 |
| Basic vestibular evaluation CPT 92540 | not published | not published | $160.18 – $412.19 | 4 |
| Basiliximab HCPCS J0480 | not published | not published | $3,678.79 – $12,680.27 | 8 |
| Bausch health Ultrasound surg HCPCS V2788 | $650.67 | $1,183.04 | not published | 0 |
| B cells total count CPT 86355 | not published | not published | $28.30 – $72.82 | 7 |
| Bcg live 50 mg intravesical suspension HCPCS J9030 | not published | not published | $2.53 – $8.17 | 8 |
| Bckdhb gene CPT 81205 | not published | not published | $71.24 – $183.33 | 7 |
| Behavior counsel obesity 15min medicare g0447 HCPCS G0447 | not published | not published | $75.36 – $193.93 | 4 |
| Belatacept 250 mg intravenous solution HCPCS J0485 | not published | not published | $2.91 – $10.69 | 8 |
| Belimumab 120 mg intravenous solution HCPCS J0490 | not published | not published | $43.72 – $149.49 | 8 |
| Bendamustine 100 mg intravenous powder for solution HCPCS J9033 | not published | not published | $1.36 – $5.71 | 8 |
| Bendamustine 25 mg/ml intravenous solution (belrapzo) HCPCS J9036 | not published | not published | $8.70 – $46.63 | 8 |
| Bendamustine 25 mg/ml intravenous solution (bendeka) HCPCS J9034 | not published | not published | $9.40 – $36.61 | 8 |
| Bendamustine 25 mg/ml intravenous solution (vivimusta) HCPCS J9056 | not published | not published | $22.43 – $78.00 | 8 |
| Benign lesion paring 2-4 CPT 11056 | $290.95 | $529.00 | $148.84 – $2,334.00 | 6 |
| Benign lesion paring 4+ CPT 11057 | not published | not published | $148.84 – $2,334.00 | 6 |
| #_benzodiazconfur CPT 80346 | $158.95 | $289.00 | $35.06 – $35.06 | 1 |
| Benztropine 1 mg/ml injection solution HCPCS J0515 | not published | not published | $18.28 – $45.99 | 5 |
| Beta 2 glycoprotein 1 antibody iga CPT 86146 | $33.55 | $61.00 | $11.77 – $49.12 | 7 |
| Beta-2 microglobulin CPT 82232 | $139.70 | $254.00 | $12.14 – $31.23 | 7 |
| Beta-amyloid 1-40 CPT 82233 | not published | not published | $96.69 – $248.82 | 4 |
| Beta-amyloid 1-42 CPT 82234 | not published | not published | $96.69 – $248.82 | 4 |
| Betamethasone acetate and sodium phos 6 mg/ml suspension for injection HCPCS J0702 | not published | not published | $7.54 – $20.44 | 5 |
| Bevacizumab 25 mg/ml intravenous solution HCPCS J9035 | not published | not published | $56.12 – $199.25 | 8 |
| Bevacizumab-awwb 25 mg/ml intravenous solution HCPCS Q5107 | not published | not published | $18.40 – $78.21 | 7 |
| Bevacizumab-bvzr 25 mg/ml intravenous solution HCPCS Q5118 | not published | not published | $19.42 – $62.62 | 7 |
| Bevacizumab injection HCPCS C9257 | not published | not published | $1.40 – $4.98 | 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.