ST MARYS GOOD SAMARITAN HOSPITAL

Code	Description	Gross	Cash	Min payer	Max payer	# insurers
RX-137245	NUSINERSEN (PF) 12 MG/5 ML INTRATHECAL SOLUTION	$455,356	$455,356	—	—	107
RX-207058	ROZANOLIXIZUMAB-NOLI 140 MG/ML SUBCUTANEOUS SOLUTION	$56,797	$56,797	—	—	65
SUP-10005701	SPACER IDENTITI NANOTEC LIF POROUS TI 10 X 18 X 55 MM 10DEG	$31,440	$20,436	—	—	16
RX-203310	RISANKIZUMAB-RZAA 60 MG/ML INTRAVENOUS SOLUTION	$30,072	$30,072	—	—	103
SUP-10005669	SPACER IDENTITI ALIF SA 9 X 42 X 30 MM 10DEG	$27,900	$18,135	—	—	11
SUP-10000434	CAGE LUMBAR ANT 12X25X33MM 10DEG MONTEREY	$27,879	$18,122	—	—	16
SUP-10000436	CAGE LUMBAR ANT 12X28X36MMX10DEG MONTEREY	$27,361	$17,785	—	—	16
SUP-10000442	CAGE LUMBAR ANT 14X28X36MM 20DEG MONTEREY	$26,900	$17,485	—	—	16
RX-201729	INCLISIRAN 284 MG/1.5 ML SUBCUTANEOUS SYRINGE	$26,119	$26,119	—	—	107
RX-500583	ALTEPLASE 100 MG INFUSION FROM PYXIS VIAL	$25,477	$25,477	—	—	91
SUP-10005770	SPACER IDENTITI LIF 6 H 22 W 55 L 10DEG	$24,497	$15,923	—	—	16
SUP-101396	CUFF BELT URNRY 4.0CM	$23,256	$15,116	—	—	16
RX-650007	F-18 FLORBETAPIR LESS THAN OR EQUAL TO 10 MCI	$21,203	$21,203	—	—	70
PX-36000000026	HC or Level VI Initial 15 Minutes	$20,143	$13,093	—	—	88
SUP-10018843	SPACER TRANSCEND 10X18X45MM 0DEG LIF PEEK	$19,813	$12,878	—	—	16
RX-500950	ROMOSOZUMAB-AQQG 105 MG/1.17 ML SUBCUTANEOUS SYRINGE (WRAPPER)	$19,323	$19,323	—	—	107
PX-36000000025	HC or Level V Initial 15 Minutes	$18,312	$11,903	—	—	88
PX-36000000024	HC or Level IV Initial 15 Minutes	$18,131	$11,785	—	—	88
SUP-10004904	PLATE INTERPROSTHETIC FEMURE LEFT 334MM	$15,620	$10,153	—	—	16
RX-108843	BELIMUMAB 400 MG INTRAVENOUS SOLUTION	$15,408	$15,408	—	—	107
RX-650027	IN-111 PENTETREOTIDE	$15,327	$15,327	—	—	106
RX-650025	IN-111 OXYQUINOLIN PER 0.5 MCI	$15,087	$15,087	—	—	102
SUP-10005348	PLATE INTERPROSTHETIC FEMURE LEFT 379MM	$14,344	$9,324	—	—	16
RX-31432	DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION	$13,725	$13,725	—	—	89
SUP-10005827	PLATE LIF AMP TWO SCREW 04 AND CNTR SCREW 15MM	$12,725	$8,271	—	—	16
SUP-10000509	CAGE SPINE TL LORDIC 10X32X10MM 8DEG TI CASCADIA	$12,492	$8,120	—	—	16
RX-105502	DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE	$12,437	$12,437	—	—	107
PX-36000000023	HC or Level III Initial 15 Minutes	$11,056	$7,186	—	—	88
SUP-10005820	PLATE LIF AMP ONE SCREW 04 W/ 2 CNTR SCREWS 15MM- BK TBL	$11,039	$7,175	—	—	16
PX-36115273001	HC Application Skin Substitute Graft Trunk/Arms/Legs >= 100 Sq Cm 1st 100 Sq Cm	$10,190	$6,624	—	—	106
RX-650024	IN-111 IBRITUMOMAB TIUX DX	$10,145	$10,145	—	—	62
RX-107750	IMMUNE GLOBULIN, GAMMA (IGG) (10 %)-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION	$10,106	$10,106	—	—	77
RX-500650	RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION FOR DESENSITIZATION	$9,890	$9,890	—	—	97
SUP-10005868	CONNECTOR OPEN-OPEN 11MM 5-6.35MM REVISION KODIAK	$9,122	$5,929	—	—	16
PX-36136556001	HC Insertion Nontunneled Centrally Inserted Central Venous Catheter >= 5 Years Old	$9,053	$5,884	—	—	106
SUP-10000705	SCREW CREO CANN PREF ANGLE 8.5X90MM	$8,872	$5,767	—	—	16
SUP-10002612	PLATE 4.5MM TI VA LCP CRVD CONDYLAR 8 HOLE 195MM RIGHT	$8,623	$5,605	—	—	16
SUP-10018601	IMPLANT RETRACTION UROLIFT CARTRIDGE PROSTATIC	$8,620	$5,603	—	—	13
RX-126653	ORITAVANCIN 400 MG INTRAVENOUS SOLUTION	$8,369	$8,369	—	—	16
PX-36110180001	HC Incision & Drainage Wound Post OP Infection Complex	$8,071	$5,246	—	—	106
SUP-10002622	PLATE 4.5MM TI VA LCP CRVD CONDYLAR 16 HOLE 336MM RIGHT	$7,880	$5,122	—	—	16
PX-72200000002	HC C-Section Delivery/Recovery Flat Rate Level 2	$7,761	$5,045	—	—	89
PX-36159414001	HC Delivery of Placenta	$7,593	$4,935	—	—	106
SUP-10003908	NAIL STERILE TIBIAL DIA 8 MM LENGTH 345 MM	$7,275	$4,729	—	—	12
PX-36000000022	HC or Level II Initial 15 Minutes	$7,273	$4,727	—	—	88
SUP-10004233	INSERT ATTUNE CRS RP SZ 5 22MM	$7,170	$4,661	—	—	16
RX-110675	BELATACEPT 250 MG INTRAVENOUS SOLUTION	$6,789	$6,789	—	—	107
SUP-10001643	STAPLE BONE CMPRSN STRL	$6,752	$4,389	—	—	16
SUP-10003917	NAIL STERILE TIBIAL DIA 10 MM LENGTH 405 MM	$6,750	$4,387	—	—	16
RX-111437	HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION	$6,748	$6,748	—	—	89

Showing top 50 of 2,206 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.