WellSpan Good Samaritan Hospital
252 S. 4th St., Lebanon, PA · Wellspan · · NPI 1407928500
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 |
|---|---|---|---|---|
| 17-hydroxypregnenolone CPT 84143 | $95.20 | $119.00 | $22.81 – $107.24 | 25 |
| 2nd order venous cath CPT 36012 | $1,457.60 | $1,822.00 | $143.13 – $389.30 | 7 |
| 3-d radiotherapy plan CPT 77295 | $8,770.40 | $10,963.00 | $203.19 – $2,365.28 | 22 |
| 5' nucleotidase - sendout CPT 83915 | $46.40 | $58.00 | $11.15 – $52.39 | 25 |
| 88334 ap bill cytologic exam each additional site CPT 88334 | $140.00 | $175.00 | $44.09 – $247.20 | 11 |
| Abd aorta w/runoff s&i CPT 75630 | $6,960.00 | $8,700.00 | $210.06 – $17,462.81 | 9 |
| Abd/low ext cath 1st CPT 36245 | $1,803.20 | $2,254.00 | $168.13 – $457.30 | 7 |
| Abd/low ext cath 2nd CPT 36246 | $1,803.20 | $2,254.00 | $317.61 – $863.91 | 7 |
| Abd/low ext cath 3rd CPT 36247 | $1,803.20 | $2,254.00 | $370.00 – $1,006.40 | 7 |
| Abd/low ext cath addl CPT 36248 | $1,803.20 | $2,254.00 | $60.73 – $165.17 | 7 |
| Abdominal CT scan (with and without contrast) CPT 74170 | $560.00 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| Abdominal CT scan (with contrast) CPT 74160 | $468.50 | $2,362.00 | $175.85 – $1,006.60 | 24 |
| Abdominal CT scan (without contrast) CPT 74150 | $273.50 | $1,610.00 | $105.04 – $602.31 | 24 |
| Abdominal MRI (with and without contrast) CPT 74183 | $706.00 | $2,486.00 | $352.78 – $2,106.92 | 24 |
| Abdominal MRI (with contrast) CPT 74182 | $639.50 | $2,350.00 | $352.78 – $2,106.92 | 24 |
| Abdominal MRI (without contrast) CPT 74181 | $457.00 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| Abdominal paracentesis w/image guidance CPT 49083 | $1,588.80 | $1,986.00 | $105.41 – $2,402.40 | 22 |
| Abdominal Ultrasound (complete) CPT 76700 | $1,753.60 | $2,192.00 | $88.36 – $602.31 | 24 |
| Abdominal Ultrasound (limited) CPT 76705 | $1,248.80 | $1,561.00 | $67.84 – $602.31 | 24 |
| Abdominoplasty 15830 CPT 15830 | not published | not published | $1,101.92 – $19,485.21 | 3 |
| Abd paracentesis/w/o image guide 49082 CPT 49082 | $1,497.60 | $1,872.00 | $68.16 – $2,402.40 | 22 |
| Ablate bone tumor(s) perq CPT 20982 | not published | not published | $1,101.92 – $38,444.24 | 3 |
| Ablation cardiac vagal inputs atrium CPT 93799 | $14,685.60 | $18,357.00 | $154.55 – $453.24 | 16 |
| Ablation cryo abd perit om CPT 49999 | $5,049.60 | $6,312.00 | $106.92 – $6,956.60 | 18 |
| Abscess drain retroperitoneal surg code CPT 49406 | $4,738.40 | $5,923.00 | $217.04 – $4,109.00 | 8 |
| Acetazolamide 500 mg solution for injection HCPCS J1120 | $339.40 | $424.25 | $15.07 – $66.71 | 10 |
| Acetylcholine receptor modulating antibody CPT 86043 | $49.60 | $62.00 | $12.05 – $53.72 | 23 |
| Acetylcysteine 200 mg/ml (20 %) intravenous solution HCPCS J0132 | $241.80 | $302.25 | $0.42 – $94.50 | 10 |
| Actigraphy testing CPT 95803 | $244.80 | $306.00 | $44.55 – $102.69 | 17 |
| Actinotherapy uv light CPT 96900 | $169.60 | $212.00 | $38.16 – $67.85 | 16 |
| Acute hepatitis panel CPT 80074 | $198.40 | $248.00 | $47.63 – $216.24 | 25 |
| Acyclovir 5 mg/ml in ns IV syringe (neo/ped) - cnr HCPCS J0133 | $39.00 | $48.75 | $0.04 – $14.00 | 10 |
| #acylcarnitineprfl CPT 82017 | $69.60 | $87.00 | $15.66 – $76.59 | 20 |
| Adenosine 3 mg/250 ml bag for osm HCPCS J0153 | $163.20 | $204.00 | $0.60 – $11.14 | 10 |
| Adenovirus antibody,serum - quest CPT 86603 | $53.60 | $67.00 | $12.87 – $83.77 | 25 |
| Administration chemotherapy IV infusion each additional hour CPT 96415 | $496.00 | $620.00 | $35.35 – $123.03 | 21 |
| Administration chemotherapy IV infusion each addl sequential infusion diff substance/drug >1 hr CPT 96417 | $406.40 | $508.00 | $70.30 – $209.71 | 21 |
| Administration chemotherapy IV infusion up to 1 hour single/initial substance/drug CPT 96413 | $1,074.40 | $1,343.00 | $156.00 – $573.39 | 21 |
| Administration chemotherapy IV push single/initial substance/drug CPT 96409 | $689.60 | $862.00 | $115.25 – $573.39 | 21 |
| Administration chemotherapy subcutaneous/im anti neoplastic hormonal CPT 96402 | $496.00 | $620.00 | $39.70 – $123.03 | 21 |
| Administration chemotherapy subcutaneous/im anti neoplastic non hormonal CPT 96401 | $496.00 | $620.00 | $62.79 – $170.78 | 21 |
| Administration immunization 1 vaccine CPT 90471 | $69.60 | $87.00 | $12.50 – $123.03 | 16 |
| Administration vaccine hepatitis b HCPCS G0010 | $23.20 | $29.00 | $5.22 – $79.77 | 17 |
| Administration vaccine influenza virus HCPCS G0008 | $105.60 | $132.00 | $12.50 – $79.77 | 21 |
| Administration vaccine pneumococcal HCPCS G0009 | $161.60 | $202.00 | $12.50 – $79.77 | 21 |
| Administration vaccine rsv monoclonal ab seasonal dose im CPT 96381 | $196.00 | $245.00 | $15.88 – $43.18 | 21 |
| #afb mycobacteria suscep. #1 CPT 87190 | $30.40 | $38.00 | $7.31 – $36.78 | 25 |
| _afb org id by sequencing rflx ast-sendout CPT 87153 | $480.00 | $600.00 | $40.45 – $523.73 | 25 |
| Air conduction bilat CPT 92552 | $127.20 | $159.00 | $10.00 – $222.83 | 21 |
| Air injection into abdomen 49400 CPT 49400 | $829.60 | $1,037.00 | $60.00 – $163.20 | 7 |
| Albumin body fluid quantitative each specimen CPT 82042 | $32.80 | $41.00 | $2.57 – $35.32 | 20 |
| Albumin (human), 25%, 50ml HCPCS P9047 | $580.80 | $726.00 | $40.31 – $339.71 | 11 |
| Albumin (human), 5%, 250 ml HCPCS P9045 | $1,429.60 | $1,787.00 | $40.31 – $354.97 | 25 |
| Albumin (microalbumin) 24 hour urine quantitative CPT 82043 | $24.00 | $30.00 | $5.78 – $27.20 | 26 |
| Albumin serum plasma or whole blood CPT 82040 | $20.80 | $26.00 | $4.56 – $22.47 | 25 |
| Alkaline phosphatase CPT 84075 | $21.60 | $27.00 | $5.18 – $23.52 | 25 |
| Allergen alpha lactalbumin ige CPT 86008 | $89.60 | $112.00 | $17.93 – $98.71 | 25 |
| Allergen egg white ige CPT 86003 | $21.60 | $27.00 | $5.22 – $33.97 | 26 |
| Alpha-fetoprotein tumor marker CPT 82105 | $69.60 | $87.00 | $16.77 – $76.14 | 25 |
| Alteplase 100 mg infusion from pyxis vial HCPCS J2997 | $16,385.20 | $20,481.50 | $102.47 – $640.22 | 25 |
| Alt/sgpt CPT 84460 | $22.40 | $28.00 | $5.30 – $24.48 | 25 |
| Aluminum - quest CPT 82108 | $105.60 | $132.00 | $25.48 – $119.75 | 25 |
| Alveoloplasty each quadrant CPT 41874 | not published | not published | $1,101.92 – $9,689.84 | 3 |
| Amino acid screen, urine CPT 82128 | $68.80 | $86.00 | $10.00 – $62.97 | 25 |
| Aminolevulinic acid delta CPT 82135 | $68.00 | $85.00 | $15.00 – $74.68 | 25 |
| Aminophylline 25 mg/ml intravenous solution (wrapper) HCPCS J0280 | $138.80 | $173.50 | $11.22 – $77.35 | 10 |
| Amiodarone 150 mg/100 ml (1.5 mg/ml) in dextrose, iso-osmotic IV HCPCS J0283 | $327.40 | $409.25 | $2.83 – $45.33 | 10 |
| Amiodarone 50 mg/ml intravenous solution HCPCS J0282 | $113.20 | $141.50 | $0.46 – $48.96 | 10 |
| Ammonia CPT 82140 | $60.80 | $76.00 | $6.25 – $66.15 | 25 |
| Amphotericin b liposomal in d5w IV syringe 1 mg/ml (neo/ped) - cnr HCPCS J0289 | $2,274.20 | $2,842.75 | $23.31 – $407.93 | 25 |
| Ampicillin 1 gram solution for injection HCPCS J0290 | $40.60 | $50.75 | $0.41 – $2.10 | 10 |
| Ampicillin-sulbactam 1.5 gram solution for injection HCPCS J0295 | $45.00 | $56.25 | $1.06 – $5.50 | 10 |
| Amputation toe interphalangeal joint CPT 28825 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Amylase CPT 82150 | $26.40 | $33.00 | $6.25 – $29.42 | 25 |
| Analysis gene f2 20210g>a variant CPT 81240 | $328.00 | $410.00 | $65.69 – $298.23 | 24 |
| Analysis gene f5 leiden variant CPT 81241 | $366.40 | $458.00 | $73.37 – $333.10 | 24 |
| Analysis; simple cranial nerv pulse gen prgrmg 95976 CPT 95976 | $75.20 | $94.00 | $36.84 – $109.82 | 21 |
| Anaplsma phgcytophlm amp prb CPT 87468 | $162.40 | $203.00 | $35.09 – $159.31 | 25 |
| Anca screen with reflex to titer -quest CPT 86021 | $62.40 | $78.00 | $6.25 – $68.33 | 25 |
| An cholangiogram percutaneous compl CPT 47531 | $1,682.40 | $2,103.00 | $97.40 – $2,448.60 | 8 |
| An fluoro guide for cvp CPT 77001 | $824.80 | $1,031.00 | $75.46 – $205.26 | 8 |
| Angio balloon ctrl dialysis seg add-on CPT 36907 | $15,871.20 | $19,839.00 | $127.98 – $348.09 | 7 |
| Angioplasty fem/pop unilat 37224 CPT 37224 | $10,859.20 | $13,574.00 | $6,420.00 – $16,056.00 | 2 |
| Angioplasty/iliac/init ves/unilat 37220 CPT 37220 | $5,580.00 | $6,975.00 | $437.68 – $16,056.00 | 3 |
| Angio tib/peroneal/init ves/unila 37228 CPT 37228 | $5,580.00 | $6,975.00 | $6,420.00 – $16,056.00 | 2 |
| Angio trnslmnl balloon same artery ini CPT 37246 | $10,860.00 | $13,575.00 | $6,420.00 – $16,056.00 | 2 |
| Angio trnslmnl balloon same vein ini CPT 37248 | $12,846.40 | $16,058.00 | $313.61 – $16,056.00 | 8 |
| Ankle X-ray CPT 73610 | $398.40 | $498.00 | $20.13 – $497.84 | 24 |
| Anodyne therapy charges pt CPT 97026 | $164.80 | $206.00 | $6.44 – $136.00 | 21 |
| Antibody bacterium, not elsewhere specified CPT 86609 | $53.60 | $67.00 | $8.88 – $58.48 | 21 |
| Antibody elution rbc reference CPT 86860 | $143.20 | $179.00 | $10.56 – $488.22 | 22 |
| Antibody identification platelet antibodies heparin-pf4 igg CPT 86022 | $62.40 | $78.00 | $6.25 – $83.40 | 25 |
| Antibody id rbc panel CPT 86870 | $1,403.20 | $1,754.00 | $10.56 – $1,027.44 | 22 |
| Antibody screen rbc CPT 86850 | $240.80 | $301.00 | $10.56 – $92.37 | 24 |
| Antibody tetanus CPT 86774 | $61.60 | $77.00 | $13.86 – $67.19 | 20 |
| Antihemophilic factor-vwf 250 unit-600 unit intravenous solution HCPCS J7187 | $6.80 | $8.50 | $1.13 – $5.08 | 25 |
| Anti mog serum - sendout CPT 86362 | $49.60 | $62.00 | $10.80 – $54.71 | 25 |
| Antineutrophil cytoplasmic antibody screen each antibody CPT 86036 | $49.60 | $62.00 | $12.05 – $54.71 | 25 |
| Antineutrophil cytoplasmic antibody titer each antibody CPT 86037 | $49.60 | $62.00 | $12.05 – $54.71 | 25 |
| Antinuclear antibodies CPT 86038 | $49.60 | $62.00 | $12.09 – $69.22 | 25 |
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.