GEORGE E WEEMS MEMORIAL HOSPITAL

Code	Description	Gross	Cash	Min payer	Max payer	# insurers
J2353	SANDOSTATIN LAR DEPOT 30MG IM KIT	$36,328	$25,430	—	—	6
C9047	caplacizumab (Cablivi) 11mg vial for inj	$24,000	$16,800	—	—	5
J0875	Dalbavancin (Dalvance) 500 MG SDV	$9,967	$6,977	—	—	6
J3380	VEDOLIZUMAB (ENTYVIO) 300 MG VIAL	$8,777	$6,144	—	—	6
J3101	TNKASE 50MG/10ML INTRAVENOUS KIT	$7,242	$5,069	—	—	6
110	ROOM & BOARD PRIVATE	$6,851	$4,796	—	—	5
120	ROOM & BOARD SEMIPRIVATE	$6,851	$4,796	—	—	5
36558	INSERT TNL CV CTH W/O SUBQ PRT/PMP5 YR/>	$5,001	$3,500	—	—	6
36578	RPLCMT CATH CTR VAD SUBQ PORT/PMP	$4,766	$3,336	—	—	6
74178	CT ABDOMEN & PELVIS W & WO CONTRAST IV	$3,191	$2,234	—	—	6
74170	CT ABDOMEN W AND WO CONTRAST IV	$3,172	$2,220	—	—	6
J3489	RECLAST 5 MG/100 ML SOLN 5 mg, 100 mL	$3,084	$2,159	—	—	6
74177	CT ABDOMEN & PELVIS W CON PO & W CON IV	$3,078	$2,155	—	—	6
J0840	CROFAB ANTIVENOM VIAL	$2,993	$2,095	—	—	6
70470	CT HEAD W AND WO CONTRAST IV	$2,887	$2,021	—	—	6
74160	CT ABDOMEN W CONTRAST	$2,887	$2,021	—	—	6
15240	SKIN FULL GRFT FACE/GENIT/HF 20 SQ CM/<	$2,795	$1,956	—	—	6
32556	PERQ DRAINAGE PLEURA INSERT CATH W/O IMG	$2,677	$1,874	—	—	6
71270	CT THORAX W W/O CONTRAST	$2,637	$1,846	—	—	6
72194	CT PELVIS W AND WO CONTRAST IV	$2,567	$1,797	—	—	6
26705	DISLC METCARP CL WITH ANEST	$2,512	$1,759	—	—	6
24065	BIOP SFT TISS UP ARM/ELBOW SUPERFICIAL	$2,477	$1,734	—	—	6
31525	LARYNGOSCOPY W/WO TRACHEOSCPY DX EX NWBN	$2,471	$1,730	—	—	6
31530	LARYNGOSCOPY W/FOREIGN BODY REMOVAL	$2,471	$1,730	—	—	6
24565	CLSD TX HMRL EPCNDYLR FX MED/LAT W/MANJ	$2,446	$1,712	—	—	6
72127	CT SPINE CERVICAL LIMITED WO CONTRAST	$2,424	$1,697	—	—	6
23655LT	CLSD TX SHLDR DISLC W/MANIP REQ ANES LT	$2,370	$1,659	—	—	5
23655RT	CLSD TX SHLDR DISLC W/MANIP REQ ANES RT	$2,370	$1,659	—	—	5
71260	CT THORAX W CONTRAST	$2,354	$1,648	—	—	6
J0897	PROLIA (DENOSUMAB) SUBQ SYRINGE 60MG	$2,043	$1,430	—	—	6
70482	CT ORBIT/IAC WO & W CONTRAST	$1,996	$1,397	—	—	6
71250	CT THORAX WO CONTRAST	$1,996	$1,397	—	—	6
72193	CT PELVIS W CONTRAST IV	$1,996	$1,397	—	—	6
72126	CT SPINE CERVICALW CON	$1,975	$1,383	—	—	6
72133	CT SPINE LUMBAR W AND WO CONTRAST IV	$1,975	$1,383	—	—	6
72130	CT SPINE THORACIC W AND WO CONTRAST IT	$1,966	$1,376	—	—	6
74150	CT ABDOMEN WO CONTRAST	$1,960	$1,372	—	—	6
74176	CT ABDOMEN AND PELVIS WO CONTRAST	$1,960	$1,372	—	—	6
72125	CT SPINE CERVICALWO CONTRAST	$1,854	$1,298	—	—	6
70488	CT FACIAL BONES W W/O CON	$1,783	$1,248	—	—	6
72132	CT SPINE LUMBAR W CONTRAST IV	$1,783	$1,248	—	—	6
73702LT	CT LOWER EXTREMITY W/WO CONTRAST IV-LT	$1,708	$1,196	—	—	5
73702RT	CT LOWER EXTREMITY W/WO CONTRAST IV-RT	$1,708	$1,196	—	—	5
73202LT	CT UPPER EXTREMITY W/WO CONTRAST IV-LT	$1,697	$1,188	—	—	5
73202RT	CT UPPER EXTREMITY W/WO CONTRAST IV-RT	$1,697	$1,188	—	—	5
J1439	FERRIC CARBOXYMALT 750MG SDV(INJECTAFER)	$1,694	$1,186	—	—	6
70481	CT ORBIT/IAC W CONTRAST	$1,690	$1,183	—	—	6
70492	CT NECK W AND WO CONTRAST IV	$1,687	$1,181	—	—	6
72129	CT SPINE THORACIC W CONTRAST IV	$1,623	$1,136	—	—	6
J3246	AGGRASTAT 12.5 MG/250 ML(50MCG/ML)PREMIX	$1,589	$1,112	—	—	6

Showing top 50 of 1,209 priced procedures, sorted by gross charge.

Data straight from this hospital's federally-mandated machine-readable file (45 CFR § 180). The compliance grade reflects how completely the hospital published the six required data elements, not the quality of care.