CMS Price Transparency Data

Ultrasound, pelvis

Facility: SSM Health St Agnes Hospital-Fond Du Lac

Billing Code: 76856 (CPT)

Factual Cost Summary (Answer Capsule)

CPT Billing Code: 76856
Insurance Median: $200
Cash Discount Price: $401
vs. Medicare Baseline: 1.87x Medicare

The contracted insurance negotiated median rate for a Ultrasound, pelvis at SSM Health St Agnes Hospital-Fond Du Lac is $200. If you are paying out-of-pocket or uninsured, the self-pay cash discount rate is $401. Compared to the federal Medicare reimbursement reference rate of $106.81, this hospital’s rate is 1.87x the Medicare baseline. Located in 430 E Division St, Fond Du Lac, WI.

Cash / Self-Pay

$401

Average discount available for prompt cash payment at this facility.

Insurance Median

$200

Median negotiated contract rate across all mapped commercial carriers.

Medicare Reference Rate

$106.81

Standard federal government reimbursement rate for this code.

Visual Cost Comparison vs. Medicare

Medicare Reference Baseline: $106.81 (100%)

Cash / Self-Pay: $401 (375%)

Insurance Median: $200 (187%)

Cash: $401 (375% of Medicare)

Ins. Median: $200 (187% of Medicare)

Understanding this gauge: We use the federal Medicare rate of $106.81 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	$78	73%
Blue Cross Blue Shield	$103 - $262	96%
Wellcare	$105	98%
Doc	$200	187%

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 $401.
Request and sign a "Waiver of Insurance Submission" to prevent automatic billing.
Verify CPT Code matches exactly: 76856.

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 CPT code 76856.
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.