CT head without contrast at SSM Health St. Agnes Hospital - Fond du Lac. CPT 70450.
What SSM Health St. Agnes Hospital - Fond du Lac publishes for this service, straight from its standard-charges file, last updated April 1, 2026.
Outpatient / ER
$1,375cash price (self-pay)
$2,500list price
$77.56–$251range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| MOLINA | Medicare Managed Care Plan | $77.56 |
| BCBS | Anthem Medicare Managed Care Plan | $103 |
| Wellcare | Medicare Managed Care Plan | $105 |
| DOC | Government | $200 |
| BCBS | Blue Preferred / Blue Preferred Plus HMO/POS | $242 |
| BCBS | Blue Access PPO | $251 |
| BCBS | Blue Traditional Traditional | $251 |
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All common services at SSM Health St. Agnes Hospital - Fond du Lac