SAMUEL MAHELONA MEMORIAL HOSPITAL

Code	Description	Gross	Cash	Min payer	Max payer	# insurers
35207	35207 REPAIR BLOOD VESSEL DIRECT HAND FINGER TechFee	$12,549	$8,157	—	—	0
J3101	tenecteplase 50 mg kit	$8,763	$5,696	—	—	6
23655	23655-Shoulder w/ Anesthesia	$7,013	$4,558	—	—	0
25565	25565-Radial&Ulnar Shaft w/ Manipulation	$7,013	$4,558	—	—	0
26742	26742-Metacarpophalangeal/Interphalangeal Joint w/ Manip	$7,013	$4,558	—	—	0
27818	27818-Trimalleolar Ankle w/ Manipulation	$7,013	$4,558	—	—	0
54700	54700-I&D Epididymis/Testis/Scrotal Space	$6,889	$4,478	—	—	0
21315	Closed Tx Nasal Fx w/o Stabilization	$6,523	$4,240	—	—	0
36556	36556 INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> TechFee	$4,988	$3,242	—	—	0
46050	46050-I&D Perianal Abscess Superficial	$4,761	$3,095	—	—	0
10140	10140-I&D Hematoma/Seroma/Fluid	$4,435	$2,883	—	—	0
99291	ER Facility Visit Level 6	$4,310	$2,802	—	—	4
114	Private Behavioral Health	$3,665	$2,382	—	—	9
124	Semi Behavioral Health	$3,665	$2,382	—	—	9
74178	CT Abdomen and Pelvis w/ + w/o Contrast	$3,500	$2,275	—	—	6
74177	CT Abdomen and Pelvis w/ Contrast	$3,350	$2,178	—	—	6
99285	ER Facility Visit Level 5	$3,292	$2,140	—	—	4
C9132	prothrombin complex 500 units/20 mL kit	$3,049	$1,982	—	—	0
35226	Repair blood vessel, direct; lower extremity	$3,000	$1,950	—	—	0
10081	10081-I&D Pilonidal Cyst Complicated	$2,868	$1,864	—	—	0
121	Semi Swing SNF	$2,700	$1,755	—	—	17
111	Private Swing SNF	$2,700	$1,755	—	—	17
74174	CT Angio Abdomen and Pelvis	$2,609	$1,696	—	—	6
74176	CT Abdomen and Pelvis w/o Contrast	$2,600	$1,690	—	—	6
0202U	Respiratory Panel PCR FSI	$2,599	$1,689	—	—	1
92960	92960 - Cardioversion; Elective	$2,543	$1,653	—	—	0
25605	25605-Distal Radial w/ Manipulation	$2,515	$1,635	—	—	0
32551	Chest Tube Activity:	$2,506	$1,629	—	—	1
99284	ER Facility Visit Level 4	$2,360	$1,534	—	—	4
71275	CT Angio Chest	$2,211	$1,437	—	—	7
73201	CT Upper Extremity w/ Contrast Left	$2,153	$1,399	—	—	7
71260	CT Chest w/ Contrast	$2,137	$1,389	—	—	7
13152	13152-Eye/Ear/Nose/Lip 26-75 cm	$2,104	$1,368	—	—	0
70491	CT Neck Soft Tissue w/ Contrast	$2,061	$1,340	—	—	7
70470	CT Brain/Head w/ + w/o Contrast	$2,017	$1,311	—	—	7
70481	CT Orbits Sella w/ Contrast	$1,975	$1,284	—	—	7
70482	CT Orbits Sella w/ + w/o Contrast	$1,958	$1,273	—	—	7
12036	12036-Scalp/Trunk/Extremity 201-300 cm	$1,912	$1,243	—	—	0
73706	CT Angio Lower Extremity Left	$1,883	$1,224	—	—	7
73206	CT Angio Upper Extremity Left	$1,883	$1,224	—	—	7
69800-4203-01	hepatitis B immune globulin (ADULT) 5 mL vial	$1,838	$1,194	—	—	0
73701	CT Lower Extremity w/ Contrast Left	$1,780	$1,157	—	—	7
59730-4203-01	hepatitis B immune globulin (ADULT) 5 mL vial	$1,748	$1,136	—	—	0
70496	CT Angio Brain/Head	$1,696	$1,102	—	—	7
12006	12006-Scalp/Neck/Trunk/Genital/Extremity 201-30 cm	$1,695	$1,102	—	—	0
95816	Rapid EEG - ED (Ceribell)	$1,691	$1,099	—	—	5
12016	12016-Face/Ear/Eyelid/Nose/Lip 126-200 cm	$1,676	$1,089	—	—	0
70498	CT Angio Neck	$1,673	$1,087	—	—	7
72132	CT Spine Lumbar w/ Contrast	$1,650	$1,073	—	—	7
70487	CT Maxillofacial w/ Contrast	$1,646	$1,070	—	—	7

Showing top 50 of 2,360 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.