SSM Health St. Agnes Hospital - Fond du Lac
430 E Division St, Fond Du Lac, WI · SSM Health · · NPI 1346228541
Published prices by procedure
Cash price is what you pay without insurance. The negotiated range spans the lowest to highest rate this hospital agreed with insurers.
| Procedure | Cash price | Gross charge | Negotiated range | Payers |
|---|---|---|---|---|
| Inj cutaquig 100 mg HCPCS J1551 | not published | not published | $10.52 – $39.50 | 8 |
| Inj cuvitru, 100 mg HCPCS J1555 | not published | not published | $13.61 – $45.23 | 8 |
| Inj, cyclophos (baxter) 5mg HCPCS J9076 | not published | not published | $3.29 – $15.82 | 6 |
| Inj cyclophos dr.reddy's 5mg HCPCS J9072 | not published | not published | $6.69 – $28.59 | 6 |
| Inj cyclophosphamd auromedic HCPCS J9071 | not published | not published | $0.37 – $1.91 | 8 |
| Inj cyclophosphamd (ingenus) HCPCS J9073 | not published | not published | $0.37 – $5.96 | 8 |
| Inj, cyclophosphamd, sandoz HCPCS J9074 | not published | not published | $2.58 – $11.85 | 8 |
| Inj, daptomycin (baxter) HCPCS J0874 | not published | not published | $0.08 – $0.20 | 5 |
| Inj, daptomycin (hospira) HCPCS J0877 | not published | not published | $0.05 – $0.12 | 5 |
| Inj daptomycin (xellia) HCPCS J0873 | not published | not published | $0.03 – $0.12 | 5 |
| Inj daxibotulinumtoxina-lanm HCPCS J0589 | not published | not published | $2.30 – $8.51 | 6 |
| Inj, decitabine (sun pharma) HCPCS J0893 | not published | not published | $0.86 – $100.52 | 3 |
| Inj delandistrogene mox rokl HCPCS J1413 | not published | not published | $2,487,672.84 – $9,043,550.16 | 5 |
| Inj disk cerv-thor ea lev CPT 62291 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Inj, donanemab-azbt, 2 mg HCPCS J0175 | not published | not published | $3.12 – $11.14 | 8 |
| Inj dupuytren cord w/enzyme CPT 20527 | not published | not published | $227.71 – $2,334.00 | 6 |
| Inj, durolane 1 mg HCPCS J7318 | not published | not published | $4.68 – $18.25 | 8 |
| Inj dx for sinogram CPT 20501 | $128.70 | $234.00 | $1,887.00 – $5,512.00 | 3 |
| Inject for sacroiliac joint HCPCS G0259 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Injection anesthetic agent(s) and/or steroid genicular nerve branches w/guidance (both sides) CPT 64454 | $1,918.40 | $3,488.00 | $523.65 – $3,030.00 | 6 |
| Injection arthrography hip without anesthesia (both sides) CPT 27093 | $584.10 | $1,062.00 | $1,887.00 – $5,512.00 | 3 |
| Injection, belinostat, 10mg HCPCS J9032 | not published | not published | $40.83 – $136.88 | 8 |
| Injection, burosumab-twza 1m HCPCS J0584 | not published | not published | $385.03 – $1,278.83 | 8 |
| Injection, cangrelor HCPCS C9460 | not published | not published | $15.21 – $51.23 | 5 |
| Injection carpal tunnel therapeutic (both sides) CPT 20526 | $458.15 | $833.00 | $227.71 – $2,334.00 | 6 |
| Injection, casimersen, 10 mg HCPCS J1426 | not published | not published | $124.63 – $522.72 | 5 |
| Injection, daratumumab 10 mg HCPCS J9145 | not published | not published | $55.33 – $177.84 | 8 |
| Injection, doxercalciferol HCPCS J1270 | not published | not published | $0.41 – $1.04 | 5 |
| Injection during cath supravalvular aortography CPT 93567 | $1,697.85 | $3,087.00 | $1,887.00 – $2,334.00 | 2 |
| Injection, edaravone, 1 mg HCPCS J1301 | not published | not published | $4.85 – $59.02 | 8 |
| Injection epidural blood patch or clot CPT 62273 | $1,501.50 | $2,730.00 | $523.65 – $3,030.00 | 6 |
| Injection estrone per 1 mg HCPCS J1435 | not published | not published | $0.87 – $0.87 | 1 |
| Injection eye drug CPT 67028 | not published | not published | $245.03 – $2,334.00 | 6 |
| Injection for arthrography wrist (both sides) CPT 25246 | $129.80 | $236.00 | $1,887.00 – $5,512.00 | 3 |
| Injection for bladder x-ray CPT 51600 | $839.30 | $1,526.00 | $1,887.00 – $5,512.00 | 3 |
| Injection for hip x-ray CPT 27095 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Injection for shoulder arthrogram or enhanced ct/mri shoulder arthography (both sides) CPT 23350 | $403.15 | $733.00 | $1,887.00 – $5,512.00 | 3 |
| Injection for spleen x-ray CPT 38200 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Injection for tear sac x-ray CPT 68850 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Injection for ureter x-ray CPT 50684 | $444.95 | $809.00 | $1,887.00 – $5,512.00 | 3 |
| Injection for ureter x-ray CPT 50690 | $237.60 | $432.00 | $1,887.00 – $5,512.00 | 3 |
| Injection, fulvestrant HCPCS J9395 | not published | not published | $7.20 – $18.13 | 5 |
| Injection glatiramer acetate HCPCS J1595 | not published | not published | $467.10 – $467.10 | 1 |
| Injection, inclisiran, 1 mg HCPCS J1306 | not published | not published | $9.68 – $33.43 | 8 |
| Injection into brain canal CPT 61026 | not published | not published | $523.65 – $3,030.00 | 6 |
| Injection into brain canal CPT 61055 | not published | not published | $227.71 – $2,334.00 | 6 |
| Injection into hemorrhoid(s) CPT 46500 | not published | not published | $689.87 – $3,030.00 | 6 |
| Injection into spinal artery CPT 62294 | not published | not published | $656.13 – $3,030.00 | 6 |
| Injection into vocal cord CPT 31513 | not published | not published | $290.14 – $2,334.00 | 6 |
| Injection intraop add-on CPT 48400 | not published | not published | $2,654.00 – $2,654.00 | 1 |
| Injection, isavuconazonium HCPCS J1833 | not published | not published | $0.77 – $2.69 | 5 |
| Injection jaw joint x-ray CPT 21116 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Injection jugular CPT 36299 | not published | not published | $1,887.00 – $5,512.00 | 3 |
| Injection, khapzory, 0.5 mg HCPCS J0642 | not published | not published | $1.30 – $3.68 | 5 |
| Injection, necitumumab, 1 mg HCPCS J9295 | not published | not published | $4.30 – $15.59 | 8 |
| Injection of HIV prep drug HCPCS G0012 | not published | not published | $53.41 – $137.45 | 4 |
| Injection of sinus tract CPT 20500 | not published | not published | $1,151.01 – $4,761.00 | 6 |
| Injection,onabotulinumtoxina HCPCS J0585 | not published | not published | $4.88 – $17.62 | 8 |
| Injection, peramivir HCPCS J2547 | not published | not published | $1.26 – $4.57 | 5 |
| Injection px peyronie ds CPT 54200 | not published | not published | $185.35 – $2,334.00 | 6 |
| Injection radioactive tracer sentinel node (both sides) CPT 38792 | $822.25 | $1,495.00 | $296.56 – $2,334.00 | 6 |
| Injection, renflexis HCPCS Q5104 | not published | not published | $19.96 – $71.49 | 7 |
| Injection, ruconest HCPCS J0596 | not published | not published | $28.37 – $94.40 | 8 |
| Injection sacroiliac joint anesthesia/steroid without or w/arthrography (both sides) HCPCS G0260 | $3,372.60 | $6,132.00 | $523.65 – $3,030.00 | 6 |
| Injection(s) anesthetic agent(s) and/or steroid femoral nerve left CPT 64447 | $786.50 | $1,430.00 | $523.65 – $3,030.00 | 6 |
| Injection(s) anesthetic agent(s) and/or steroid other peripheral nerve/branch (both sides) CPT 64450 | $1,647.80 | $2,996.00 | $523.65 – $3,030.00 | 6 |
| Injection(s) anesthetic agent(s)/steroid lumb/s transforaminal epidural w/img single (both sides) CPT 64483 | $4,455.00 | $8,100.00 | $656.13 – $3,030.00 | 7 |
| Injection(s) diagnostic/therapeutic agent facet cervical/thoracic 2nd level CPT 64491 | $3,955.05 | $7,191.00 | $1,887.00 – $5,512.00 | 3 |
| Injection(s) diagnostic/therapeutic agent facet cervical/thoracic single level CPT 64490 | $4,495.70 | $8,174.00 | $656.13 – $3,030.00 | 6 |
| Injection(s) diagnostic/therapeutic agent facet lumbar/sacral 2nd level w/image guidance CPT 64494 | $3,955.05 | $7,191.00 | $433.00 – $5,512.00 | 4 |
| Injection(s) diagnostic/therapeutic agent facet lumbar/sacral single level CPT 64493 | $4,495.70 | $8,174.00 | $656.13 – $3,030.00 | 7 |
| Injection(s) epidural/subarachnoid cervical/thoracic needle placement w/guidance CPT 62321 | $1,696.75 | $3,085.00 | $523.65 – $3,030.00 | 6 |
| Injection(s) epidural/subarachnoid lumbar/sacral needle placement w/guidance CPT 62323 | $1,708.85 | $3,107.00 | $523.65 – $3,030.00 | 6 |
| Injection, siltuximab HCPCS J2860 | not published | not published | $130.55 – $424.63 | 8 |
| Injection(s) tendon sheath/ligament aponeurosis single (both sides) CPT 20550 | $937.75 | $1,705.00 | $227.71 – $2,334.00 | 6 |
| Injection(s) trigger point(s) single/multiple 1 or 2 muscle(s) CPT 20552 | $717.75 | $1,305.00 | $227.71 – $2,334.00 | 6 |
| Injection(s) trigger point(s) single/multiple >= 3 muscle(s) CPT 20553 | $811.80 | $1,476.00 | $227.71 – $2,334.00 | 6 |
| Injection therapeutic/prophylactic/diagnostic each addl sequential IV push new substance/drug CPT 96375 | $213.40 | $388.00 | $34.74 – $89.39 | 4 |
| Injection therapeutic/prophylactic/diagnostic each addl sequential IV push same substance/drug CPT 96376 | $213.40 | $388.00 | not published | 0 |
| Injection therapeutic/prophylactic/diagnostic IV push single/initial substance/drug CPT 96374 | $213.40 | $388.00 | $157.79 – $406.05 | 4 |
| Injection therapeutic/prophylactic/diagnostic subcutaneous/im CPT 96372 | $59.40 | $108.00 | $53.41 – $137.45 | 4 |
| Injection treatment of eye CPT 66020 | not published | not published | $1,712.02 – $4,761.00 | 6 |
| Injection treatment of eye CPT 66030 | not published | not published | $1,712.02 – $4,761.00 | 6 |
| Injection treatment of nerve CPT 64605 | not published | not published | $1,448.59 – $7,791.00 | 6 |
| Injection treatment of nerve CPT 64610 | not published | not published | $1,448.59 – $7,791.00 | 6 |
| Injection treatment of nerve CPT 64681 | not published | not published | $656.13 – $3,030.00 | 6 |
| Injection treatment of nose CPT 30200 | not published | not published | $400.09 – $2,334.00 | 6 |
| Inject sacroiliac joint CPT 27096 | $1,721.50 | $3,130.00 | $1,887.00 – $2,654.00 | 3 |
| Inject/treat eye socket CPT 67500 | not published | not published | $235.46 – $2,334.00 | 6 |
| Inject/treat eye socket CPT 67505 | not published | not published | $235.46 – $2,334.00 | 6 |
| Inject/treat eye socket CPT 67515 | not published | not published | $235.46 – $2,334.00 | 6 |
| Inj efgart-alfa 2mg hya-qvfc HCPCS J9334 | not published | not published | $25.69 – $90.12 | 8 |
| Inj eflapegrastim-xnst 0.1mg HCPCS J1449 | not published | not published | $23.97 – $74.42 | 8 |
| Inj., emapalumab-lzsg, 1 mg HCPCS J9210 | not published | not published | $294.58 – $1,025.21 | 8 |
| Inj., emicizumab-kxwh 0.5 mg HCPCS J7170 | not published | not published | $43.52 – $141.62 | 8 |
| Inj epidural sgl cerv-thor without img CPT 62320 | $1,097.80 | $1,996.00 | $523.65 – $3,030.00 | 6 |
| Inj epidural sgl lumb-sacral without img CPT 62322 | $1,072.50 | $1,950.00 | $656.13 – $3,030.00 | 6 |
| Inj, epinephrine (belcher) HCPCS J0173 | not published | not published | $2.48 – $6.48 | 4 |
| Inj., eravacycline, 1 mg HCPCS J0122 | not published | not published | $1.04 – $3.30 | 8 |
| Inj, etelcalcetide, 0.1 mg HCPCS J0606 | not published | not published | $1.85 – $12.85 | 5 |
A missing value means the hospital did not publish that price — it never means the price is zero. Real bills can add facility fees, supplies and professional fees; see our methodology.