MRI lower back without contrast at SSM Health St. Agnes Hospital - Fond du Lac. CPT 72148.
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
$2,257cash price (self-pay)
$4,104list price
$177–$508range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| MOLINA | Medicare Managed Care Plan | $177 |
| BCBS | Anthem Medicare Managed Care Plan | $236 |
| Wellcare | Medicare Managed Care Plan | $241 |
| DOC | Government | $455 |
| BCBS | Blue Preferred / Blue Preferred Plus HMO/POS | $490 |
| BCBS | Blue Access PPO | $508 |
| BCBS | Blue Traditional Traditional | $508 |
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All common services at SSM Health St. Agnes Hospital - Fond du Lac