CMS Price Transparency Data

Hip or knee replacement (inpatient stay)

Facility: SSM Health St Agnes Hospital-Fond Du Lac

Billing Code: 470 (MS-DRG)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 470
Insurance Median: $25,808
Cash Discount Price: Unavailable
vs. Medicare Baseline: 1.84x Medicare

The contracted insurance negotiated median rate for a Hip or knee replacement (inpatient stay) at SSM Health St Agnes Hospital-Fond Du Lac is $25,808. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is unavailable. Compared to the federal Medicare reimbursement reference rate of $14,044.15, this hospital’s rate is 1.84x the Medicare baseline. Located in 430 E Division St, Fond Du Lac, WI.

Cash / Self-Pay

Unavailable

Average discount available for prompt cash payment at this facility.

Insurance Median

$25,808

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$14,044.15

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $14,044.15 (100%)

Insurance Median: $25,808 (184%)

Ins. Median: $25,808 (184% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $14,044.15 as the cost baseline. Rates below the baseline represent excellent value. In-network commercial rates commonly hover around 150% - 250% of Medicare, while rates exceeding 300% are elevated. Hover over the green and blue markers to view detailed calculations.

Out-of-Pocket Cost Estimator

Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.

Billing Status

Remaining Deductible ($)

Your Coinsurance Rate (%)

Input your details and click calculate to compare out-of-pocket costs.

Commercial Insurance Negotiated Rates

Negotiated contract ranges established by major commercial carriers at this facility.

Carrier / Plan Group	Contract Rate Range	vs. Medicare Reference
Molina	$10,593	75%
Blue Cross Blue Shield	$14,124 - $30,085	101%
Dean Health Plan	$14,124	101%
Humana	$14,124	101%
Icare	$14,124	101%
Network Health	$14,124	101%
UnitedHealthcare	$14,124 - $29,055	101%
Wellcare	$14,406	103%
Faboh	$21,058	150%
Health Payment System	$25,244	180%
Quartz Health Solutions	$26,373	188%
Centivo	$31,441 - $34,799	224%
Wps Health Insurance	$33,130	236%
Trilogy	$34,084	243%
The Alliance	$38,482	274%
Network Health Plan	$39,681	283%

Self-Pay Upfront Cash Action Plan

Request a "Self-Pay classification" with the billing desk before receiving care.
Ask for a written "Prompt-Pay Discount" agreement quoting the price of $X.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify MS-DRG Code matches exactly: 470.

Insurance In-Network Protection Plan

Contact your insurance company to confirm SSM Health St Agnes Hospital-Fond Du Lac is fully in-network.
Ask your insurer if "Prior Authorization" is required for MS-DRG code 470.
Confirm the specific physician or imaging center is also in-network (not just the hospital building).
Audit your Explanation of Benefits (EOB) against the final itemized hospital invoice.