| Hospital | Address | Code | Price | Last Updated |
|---|---|---|---|---|
| Ascension Calumet Hospital | 614 Memorial Dr, Chilton | J0775 | $63 [source] | 4 years ago |
| Aspirus Divine Savior Hospital | 2817 New Pinery Rd, Portage | J0775 | $65 [source] | 4 years ago |
| Midwest Orthopedic Specialty Hospital, Llc | 10101 S 27Th St, Franklin | J0775 | $105 [source] | 4 years ago |
| Chippewa Valley Hospital & Oakview Care Center, Inc. | 1220 3Rd Ave W, Durand | J0775 | $146 [source] | 4 years ago |
| Orthopaedic Hospital Of Wisconsin | 475 W River Woods Pkwy, Milwaukee | J0775 | $149 [source] | 4 years ago |