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, eteplirsen, 10 mg HCPCS J1428 | not published | not published | $125.57 – $522.72 | 5 |
| Inj, evinacumab-dgnb, 5mg HCPCS J1305 | not published | not published | $148.22 – $507.23 | 8 |
| Inj., evomela, 1 mg HCPCS J9246 | not published | not published | $13.53 – $49.01 | 8 |
| Inj, exagamglogene autotem HCPCS J3392 | not published | not published | $1,725,680.00 – $6,348,870.00 | 5 |
| Inj, factor x, (human), 1iu HCPCS J7175 | not published | not published | $7.46 – $25.94 | 8 |
| Inj, faricimab-svoa, 0.1mg HCPCS J2777 | not published | not published | $24.29 – $95.96 | 8 |
| Inj. fe derisomaltose 10 mg HCPCS J1437 | not published | not published | $15.81 – $56.55 | 8 |
| Inj fensolvi 0.25 mg HCPCS J1951 | not published | not published | $108.98 – $371.56 | 8 |
| Inj., fibryga, 1 mg HCPCS J7177 | not published | not published | $0.92 – $3.02 | 8 |
| Inj fluphenazine hcl 1.25 mg HCPCS J2679 | not published | not published | $7.87 – $20.94 | 5 |
| Inj, focinvez, 1mg HCPCS J1434 | not published | not published | $1.84 – $8.50 | 6 |
| Inj for ext venography CPT 36005 | $396.55 | $721.00 | $1,887.00 – $5,512.00 | 3 |
| Inj for mammo ductogram CPT 19030 | $231.00 | $420.00 | $1,887.00 – $5,512.00 | 3 |
| Inj, fosaprepitant (teva) HCPCS J1456 | not published | not published | $0.03 – $2.15 | 8 |
| Inj fosnetupitant, palonoset HCPCS J1454 | not published | not published | $377.89 – $1,791.69 | 8 |
| Inj., fremanezumab-vfrm 1 mg HCPCS J3031 | not published | not published | $11.02 – $11.02 | 1 |
| Inj, fulvestrant (fresenius) HCPCS J9394 | not published | not published | $3.65 – $52.33 | 8 |
| Inj, fulvestrant (teva) HCPCS J9393 | not published | not published | $31.25 – $80.42 | 5 |
| Inj, gadopiclenol, 1 ml HCPCS A9573 | not published | not published | $3.82 – $9.75 | 4 |
| Inj, ganciclovir (exela) HCPCS J1574 | not published | not published | $163.35 – $163.35 | 1 |
| Inj gemcitabine hcl (accord) HCPCS J9196 | not published | not published | $9.52 – $25.43 | 5 |
| Inj givosiran 0.5 mg HCPCS J0223 | not published | not published | $90.69 – $314.37 | 8 |
| Inj glofitamab gxbm, 2.5 mg HCPCS J9286 | not published | not published | $2,148.51 – $7,543.80 | 8 |
| Inj glycopyrrolate fres kabi HCPCS J1598 | not published | not published | $1.83 – $5.49 | 5 |
| Inj glycopyrrolate, glyrx-pf HCPCS J1597 | not published | not published | $5.33 – $5.33 | 1 |
| Inj golodirsen 10 mg HCPCS J1429 | not published | not published | $522.72 – $522.72 | 1 |
| Inj, granisetron, xr, 0.1 mg HCPCS J1627 | not published | not published | $2.41 – $15.00 | 8 |
| Inj., guselkumab, 1 mg HCPCS J1628 | not published | not published | $50.19 – $200.16 | 8 |
| Inj., haegarda 10 units HCPCS J0599 | not published | not published | $39.34 – $39.34 | 1 |
| Inj, hemgenix, per tx dose HCPCS J1411 | not published | not published | $2,768,587.50 – $10,100,475.00 | 5 |
| Inj heparin, pfizer, 1000u HCPCS J1643 | not published | not published | $3.23 – $9.59 | 5 |
| Inj. herceptin hylecta, 10mg HCPCS J9356 | not published | not published | $43.76 – $171.68 | 8 |
| Inj, hercessi, 10 mg HCPCS Q5146 | not published | not published | $24.34 – $288.17 | 6 |
| Inj herzuma 10 mg HCPCS Q5113 | not published | not published | $41.21 – $195.97 | 7 |
| Inj hrt cath w/s&i nonsel p-art angrp CPT 93568 | $1,439.90 | $2,618.00 | $1,887.00 – $2,334.00 | 2 |
| Inj hrt cath w/s&i sel hrt ang CPT 93563 | not published | not published | $1,887.00 – $2,334.00 | 2 |
| Inj hrt cath w/s&i sel hrt art CPT 93564 | not published | not published | $1,887.00 – $2,334.00 | 2 |
| Inj hrt cath w/s&i sel left vent CPT 93565 | $1,072.50 | $1,950.00 | $1,887.00 – $2,334.00 | 2 |
| Inj hrt cath w/s&i sel right vent CPT 93566 | not published | not published | $1,887.00 – $2,334.00 | 2 |
| Inj human fibrinogen con nos HCPCS J7178 | not published | not published | $1.12 – $4.03 | 8 |
| Inj hydroxocobalamin IV 25mg HCPCS J3424 | not published | not published | $4.08 – $14.11 | 5 |
| Inj hydroxyprogst capoat nos HCPCS J1729 | not published | not published | $92.91 – $92.91 | 1 |
| Inj., ibalizumab-uiyk, 10 mg HCPCS J1746 | not published | not published | $59.63 – $209.98 | 8 |
| Inj, idacio, 1 mg HCPCS Q5144 | not published | not published | $40.89 – $40.89 | 1 |
| Inj imip 4 cilas 4 releb 2mg HCPCS J0742 | not published | not published | $2.70 – $6.81 | 5 |
| Inj, imm glob bivigam, 500mg HCPCS J1556 | not published | not published | $60.93 – $208.63 | 8 |
| Inj, immphentiv, 20 mcg HCPCS J2373 | not published | not published | $0.15 – $0.38 | 5 |
| Inj. inebilizumab-cdon, 1 mg HCPCS J1823 | not published | not published | $382.99 – $1,318.78 | 8 |
| Inj/inf neurolyt sbst spinal canal lesion 62282 CPT 62282 | not published | not published | $656.13 – $3,030.00 | 6 |
| Inj. insulin (fiasp) HCPCS J1812 | not published | not published | $5.23 – $5.23 | 1 |
| Inj intralesional <= 7 lsn(s) CPT 11900 | $380.60 | $692.00 | $148.84 – $2,334.00 | 6 |
| Inj intralesional > 7 lsns CPT 11901 | $406.45 | $739.00 | $148.84 – $2,334.00 | 6 |
| Inj, invega hafyera/trinza HCPCS J2427 | not published | not published | $9.95 – $34.35 | 8 |
| Inj ivig privigen 500 mg HCPCS J1459 | not published | not published | $38.41 – $134.16 | 8 |
| Inj, ixinity, 1 i.u HCPCS J7213 | not published | not published | $1.45 – $5.99 | 8 |
| Inj. jivi 1 iu HCPCS J7208 | not published | not published | $2.07 – $6.67 | 8 |
| Inj, kovaltry, 1 i.u HCPCS J7211 | not published | not published | $1.20 – $4.03 | 8 |
| Inj labetalol hcl hikma, 5mg HCPCS J1921 | not published | not published | $1.50 – $3.76 | 5 |
| Inj., lanadelumab-flyo, 1 mg HCPCS J0593 | not published | not published | $66.16 – $280.01 | 6 |
| Inj, lanreotide, (cipla) 1mg HCPCS J1932 | not published | not published | $15.25 – $83.52 | 8 |
| Inj, lecanemab-irmb, 1 mg HCPCS J0174 | not published | not published | $1.01 – $3.61 | 8 |
| Inj lefamulin 1 mg HCPCS J0691 | not published | not published | $2.23 – $2.23 | 1 |
| Inj, lenacapavir, 1 mg HCPCS J1961 | not published | not published | $17.20 – $59.85 | 8 |
| Inj levocarnitine per 1 gm HCPCS J1955 | not published | not published | $26.82 – $69.58 | 5 |
| Inj levoleucovorin nos 0.5mg HCPCS J0641 | not published | not published | $0.02 – $0.12 | 5 |
| Inj, levothyroxine, freskabi HCPCS J0651 | not published | not published | $4.13 – $13.48 | 8 |
| Inj, levothyroxine, hikma HCPCS J0652 | not published | not published | $5.56 – $13.99 | 5 |
| Inj, lidocaine w epinephrine HCPCS J2004 | not published | not published | $0.08 – $0.08 | 1 |
| Inj, linezolid (hospira) HCPCS J2021 | not published | not published | $6.97 – $22.52 | 5 |
| Inj, lovotibeglogene autotem HCPCS J3394 | not published | not published | $2,426,477.99 – $8,692,942.50 | 5 |
| Inj. lumasiran, 0.5 mg HCPCS J0224 | not published | not published | $252.73 – $865.79 | 8 |
| Inj., lumoxiti, 0.01 mg HCPCS J9313 | not published | not published | $17.55 – $63.67 | 5 |
| Inj luxturna 1 billion vec g HCPCS J3398 | not published | not published | $2,302.23 – $8,639.12 | 5 |
| Inj lwr xtr fscl pln blk uni w/wo image CPT 64473 | $3,866.50 | $7,030.00 | not published | 0 |
| Inj marstacim-hncq, 0.5 mg HCPCS J7172 | not published | not published | $38.39 – $98.80 | 5 |
| Inj. meloxicam 1 mg HCPCS J1738 | not published | not published | $10.23 – $10.23 | 1 |
| Inj melpha hydroch nos 50 mg HCPCS J9245 | not published | not published | $78.67 – $363.97 | 8 |
| Inj melphalan (hepzato) 1 mg HCPCS J9248 | not published | not published | $601.11 – $2,106.67 | 8 |
| Inj mepivacaine hcl/10 ml HCPCS J0670 | not published | not published | $3.85 – $9.67 | 5 |
| Inj, meropenem (b. braun) HCPCS J2184 | not published | not published | $2.25 – $5.64 | 5 |
| Inj., meropenem, vaborbactam HCPCS J2186 | not published | not published | $1.67 – $5.73 | 5 |
| Inj meropenem (wg crit care) HCPCS J2183 | not published | not published | $1.76 – $4.49 | 5 |
| Inj metaraminol bitartrate HCPCS J0380 | not published | not published | $2.64 – $2.64 | 1 |
| Inj, micafungin (par pharm) HCPCS J2247 | not published | not published | $0.34 – $0.84 | 5 |
| Inj, mirikizumab-mrkz, 1 mg HCPCS J2267 | not published | not published | $24.49 – $123.57 | 8 |
| Inj mogamulizumab-kpkc, 1 mg HCPCS J9204 | not published | not published | $193.90 – $662.44 | 8 |
| Inj, motixafortide, 0.25 mg HCPCS J2277 | not published | not published | $19.86 – $68.66 | 8 |
| Inj, moxifloxacin 100 mg HCPCS J2280 | not published | not published | $9.37 – $23.55 | 5 |
| Inj moxifloxacin (fres kabi) HCPCS J2281 | not published | not published | $6.68 – $16.80 | 5 |
| Inj multihance HCPCS A9577 | not published | not published | $2.00 – $4.95 | 4 |
| Inj multihance multipack HCPCS A9578 | not published | not published | $1.99 – $4.87 | 4 |
| Inj. mycophenolate mofetil HCPCS J7519 | not published | not published | $0.34 – $1.12 | 5 |
| Inj naloxone hydrochloride HCPCS J2310 | not published | not published | $9.42 – $23.69 | 4 |
| Inj. naxitamab-gqgk, 1 mg HCPCS J9348 | not published | not published | $513.67 – $1,748.64 | 8 |
| Inj nephrosto/ureterogram w/img exstng access CPT 50431 | $931.70 | $1,694.00 | $517.28 – $3,030.00 | 6 |
| Inj, nithiodote, 3mg / 125mg HCPCS J0211 | not published | not published | $1.62 – $5.91 | 5 |
| Inj, nogapendekin pmln, 1mcg HCPCS J9028 | not published | not published | $70.73 – $258.29 | 8 |
| Inj non-compmd foam sclrsnt mlt trncl veins same leg CPT 36466 | not published | not published | $1,530.61 – $4,761.00 | 6 |
| Inj non-compmd foam sclrsnt sgl trncl vein CPT 36465 | not published | not published | $1,530.61 – $4,761.00 | 6 |
| Inj ocrelizumab 1mg hya-ocsq HCPCS J2351 | not published | not published | $36.04 – $92.76 | 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.