Supplies, drugs & other prices at SSM Health St. Agnes Hospital-fond Du Lac
Fond Du Lac, WI · every code in this section with a posted price and a Medicare benchmark.
62 codes. Prices are the hospital's own posted facility charges.
Compare against other hospitals interactively →
| Procedure | Posted cash | Posted gross | × Medicare |
|---|---|---|---|
| 2d tee w or w/o fol w/con,in (C8925) | $1,199 | $2,180 | 1.5× |
| 2d tte w or w/o fol w/con,fu (C8924) | $506 | $920 | 1.5× |
| Abltj perc cryoabltj img gdn lxtr/perph nerve (0441T) | $3,433.10 | $6,242 | 1.8× |
| Admin hepatitis b vaccine (G0010) | $35.20 | $64 | 0.8× |
| Admin influenza virus vac (G0008) | $49.50 | $90 | 1.1× |
| Admin pneumococcal vaccine (G0009) | $49.50 | $90 | 1.1× |
| Ca screen;pelvic/breast exam (G0101) | $47.93 | $87.15 | 0.5× |
| Chemo extend iv infus w/pump (G0498) | $382.25 | $695 | 1.2× |
| Diab manage trn per indiv (G0108) | $104.50 | $190 | 1.9× |
| Diab manage trn ind/group (G0109) | $59.95 | $109 | 3.7× |
| Direct refer hospital observ (G0379) | $74.80 | $136 | 0.1× |
| Drug test def 1-7 classes (G0480) | $188.65 | $343 | 1.6× |
| Ekg tracing for initial prev (G0404) | $170.50 | $310 | 6.0× |
| Elec stim other than wound (G0283) | $68.20 | $124 | 5.4× |
| Group mnt 2 or more 30 mins (G0271) | $56.65 | $103 | 3.3× |
| Hbot, full body chamber, 30m (G0277) | $365.75 | $665 | 2.7× |
| Home sleep test/type 3 porta (G0399) | $630.30 | $1,146 | 3.0× |
| Hospital outpt clinic visit (G0463) | $173.25 | $315 | 1.3× |
| Initial preventive exam (G0402) | $175.75 | $319.54 | 1.3× |
| Inj for sacroiliac jt anesth (G0260) range across 2 matching MRF lines |
$1,686.30–$3,372.60 | $3,066–$6,132 | varies |
| Mra w/cont, abd (C8900) | $2,425.50 | $4,410 | 7.0× |
| Mra w/cont, chest (C8909) | $2,373.25 | $4,315 | 6.9× |
| Mra w/cont, lwr ext (C8912) | $2,356.20 | $4,284 | 6.8× |
| Mra w/o cont, abd (C8901) | $2,310 | $4,200 | 9.8× |
| Mra w/o cont, chest (C8910) | $2,260.50 | $4,110 | 9.6× |
| Mra w/o cont, lwr ext (C8913) | $2,244 | $4,080 | 9.5× |
| Mra w/o cont, pelvis (C8919) | $2,045.45 | $3,719 | 8.7× |
| Mra w/o fol w/cont, abd (C8902) | $2,547.05 | $4,631 | 7.4× |
| Mra w/o fol w/cont, chest (C8911) | $2,492.05 | $4,531 | 7.2× |
| Mra w/o fol w/cont, lwr ext (C8914) | $2,474.45 | $4,499 | 7.2× |
| Mra w/o fol w/cont, pelvis (C8920) | $2,305.60 | $4,192 | 6.7× |
| Mra, w/dye, spinal canal (C8931) | $2,426.60 | $4,412 | 7.0× |
| Mra, w/dye, upper extremity (C8934) | $2,494.80 | $4,536 | 7.2× |
| Mra, w/o dye, upper extr (C8935) | $2,376 | $4,320 | 10.1× |
| Mri w/cont, breast, bi (C8906) | $4,401.10 | $8,002 | 12.8× |
| Mri w/cont, breast, uni (C8903) | $2,356.20 | $4,284 | 13.6× |
| Mri w/o fol w/cont, breast, (C8908) | $4,620.55 | $8,401 | 13.4× |
| Mri w/o fol w/cont, brst, un (C8905) | $2,474.45 | $4,499 | 7.2× |
| Obtaining screen pap smear (Q0091) | $20.24 | $36.80 | 0.7× |
| Opps service,sched team conf (G0175) | $221.10 | $402 | 0.5× |
| Oth resp proc, group (G0239) | $129.25 | $235 | 3.5× |
| Oth resp proc, indiv (G0238) | $41.80 | $76 | 1.5× |
| Perc d-e cor revasc chro sin (C9607) unusually low: confirm this is the full procedure |
$7,680.20 | $13,964 | 0.4× |
| Perc d-e cor revasc t cabg s (C9604) | $7,313.90 | $13,298 | 0.6× |
| Perc d-e cor stent ather s (C9602) | $10,542.40 | $19,168 | 0.6× |
| Perc drug-el cor stent sing (C9600) | $7,279.80 | $13,236 | 0.6× |
| Perq Sacral Augmt Bilat Inj (0201T) | $6,249.65 | $11,363 | 0.9× |
| Prostate biopsy, any mthd (G0416) range across 2 matching MRF lines |
$400.40–$686.95 | $728–$1,249 | varies |
| Psa screening (G0103) | $136.95 | $249 | 7.1× |
| Rbc DNA hea 35 ag 11 bld grp whl bld cmn allel (0001U) | $1,354.10 | $2,462 | 1.9× |
| Revasc intra lithotrip-stent (C9765) | $17,672.05 | $32,131 | 1.0× |
| Revasc intravasc lithotripsy (C9764) | $17,074.20 | $31,044 | 1.5× |
| Revasc lithotrip tibi/perone (C9772) | $14,318.70 | $26,034 | 1.3× |
| Tcat Rmvl/Debulk Icar Mass Suction Device Perq (0644T) | $8,390.80 | $15,256 | 1.5× |
| Therapeutic procd strg endur (G0237) | $49.50 | $90 | 1.7× |
| Trauma respons w/hosp criti (G0390) range across 4 matching MRF lines |
$3,603.05–$5,503.85 | $6,551–$10,007 | varies |
| Trim nail(s) (G0127) | $55.55 | $101 | 1.0× |
| Trluml Perip Athrc Brchiocph (0237T) | $11,543.40 | $20,988 | 1.0× |
| Tte w or w/o fol w/con,stres (C8928) | $884.40 | $1,608 | 1.1× |
| Tte w or w/o fol w/cont, com (C8921) | $1,199 | $2,180 | 1.5× |
| Tte w or wo fol wcon,doppler (C8929) | $2,168.65 | $3,943 | 2.8× |
| Unsched dialysis esrd pt hos (G0257) | $680.90 | $1,238 | 1.0× |
A range means this hospital published different amounts on matching machine-readable-file lines. We show the lowest–highest posted amount because we cannot tell from the published file which line would apply to a particular visit.