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 |
|---|---|---|---|---|
| Lactate dehydrogenase (ldh) CPT 83615 | $25.00 | $31.00 | $6.04 – $27.42 | 25 |
| Lactated ringers intravenous solution HCPCS J7120 | $32.80 | $41.00 | $1.83 – $8.06 | 9 |
| Lactic acid CPT 83605 | $75.20 | $94.00 | $10.00 – $52.53 | 25 |
| Lactoferrin fecal qualitative CPT 83630 | $82.40 | $103.00 | $15.39 – $90.28 | 25 |
| Laparo ablate renal cyst CPT 50541 | not published | not published | $1,101.92 – $31,107.25 | 3 |
| Laparoscopy lysis CPT 58660 | not published | not published | $1,101.92 – $17,432.25 | 3 |
| Laparoscopy tubal block 58671 CPT 58671 | not published | not published | $1,101.92 – $17,432.25 | 3 |
| Lead capillary CPT 83655 | $50.40 | $63.00 | $12.11 – $54.98 | 25 |
| Leg Vein Ultrasound (DVT study, both legs) CPT 93970 | $1,214.40 | $1,518.00 | $183.33 – $498.64 | 21 |
| Leucovorin calcium 100 mg solution for injection (1 mg rounding) HCPCS J0640 | $131.80 | $164.75 | $3.49 – $88.48 | 10 |
| Levetiracetam 500 mg/5 ml intravenous solution HCPCS J1953 | $21.00 | $26.25 | $0.04 – $8.75 | 10 |
| Levetiracetam therapeutic drug level CPT 80177 | $55.20 | $69.00 | $13.25 – $60.16 | 25 |
| Levofloxacin 250 mg/50 ml in 5 % dextrose intravenous piggyback HCPCS J1956 | $165.00 | $206.25 | $1.93 – $8.49 | 10 |
| Levothyroxine 100 mcg intravenous powder for solution HCPCS J0650 | $750.80 | $938.50 | $7.46 – $254.10 | 10 |
| Lidocaine (pf) 4 mg/ml (0.4 %) in 5 % dextrose intravenous solution HCPCS J2002 | $114.40 | $143.00 | $0.01 – $70.00 | 24 |
| Linezolid in 5% dextrose in water 600 mg/300 ml intravenous piggyback HCPCS J2020 | $122.60 | $153.25 | $3.87 – $36.44 | 10 |
| Lipase CPT 83690 | $28.00 | $35.00 | $6.25 – $31.28 | 25 |
| Lip exc/transverse wedge/w closure 40510 CPT 40510 | not published | not published | $1,101.92 – $9,689.84 | 3 |
| Lipoprotein blood quant CPT 83704 | $170.40 | $213.00 | $25.64 – $155.22 | 21 |
| Lipoprotein direct measurement hdl CPT 83718 | $34.40 | $43.00 | $8.19 – $37.18 | 25 |
| Lipoprotein direct measurement ldl CPT 83721 | $44.00 | $55.00 | $10.50 – $47.67 | 25 |
| Lithium therapeutic drug level CPT 80178 | $27.20 | $34.00 | $6.61 – $30.01 | 25 |
| Liver ds alys 3 bmrk srm alg CPT 81517 | $2,094.40 | $2,618.00 | $102.48 – $528.57 | 23 |
| Liver Function Test CPT 80076 | $25.00 | $43.00 | $8.17 – $37.09 | 25 |
| Lorazepam 2 mg/ml injection (wrapper) HCPCS J2060 | $25.20 | $31.50 | $1.04 – $5.50 | 10 |
| Lower Back (Lumbar Spine) CT scan (with and without contrast) CPT 72133 | $569.00 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| Lower Back (Lumbar Spine) CT scan (with contrast) CPT 72132 | $472.00 | $2,350.00 | $188.19 – $2,106.92 | 24 |
| Lower Back (Lumbar Spine) CT scan (without contrast) CPT 72131 | $286.00 | $1,610.00 | $105.04 – $602.31 | 24 |
| Lower Back (Lumbar Spine) MRI (with and without contrast) CPT 72158 | $700.50 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| Lower Back (Lumbar Spine) MRI (with contrast) CPT 72149 | $635.50 | $2,350.00 | $352.78 – $2,106.92 | 24 |
| Lower Back (Lumbar Spine) MRI (without contrast) CPT 72148 | $454.00 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| Lower Back (Lumbar Spine) X-ray CPT 72100 | $484.00 | $605.00 | $25.25 – $602.31 | 24 |
| Lung Function Test (Spirometry) CPT 94010 | $324.00 | $405.00 | $18.75 – $270.46 | 21 |
| Lung perfusion imaging CPT 78580 | $1,713.60 | $2,142.00 | $98.75 – $2,259.58 | 23 |
| Lymphatics/lymph node imaging CPT 78195 | $2,225.60 | $2,782.00 | $225.00 – $2,961.19 | 23 |
| Macro exam dissect molec study ea CPT 88387 | $368.00 | $460.00 | $21.60 – $151.27 | 11 |
| Macroscopic exam arthropod CPT 87168 | $16.80 | $21.00 | $3.78 – $27.78 | 20 |
| Macroscopic exam parasite CPT 87169 | $18.40 | $23.00 | $4.14 – $27.78 | 20 |
| Magnesium CPT 83735 | $30.00 | $47.00 | $6.70 – $31.00 | 26 |
| Magnesium sulfate 2 gram/50 ml (4 %) in water intravenous piggyback HCPCS J3475 | $112.80 | $141.00 | $0.36 – $3.43 | 10 |
| Manipulation chest wall demonstration/evaluation subsequent CPT 94668 | $240.00 | $300.00 | $54.00 – $222.83 | 16 |
| Manipulation chest wall initial demonstration/evaluation CPT 94667 | $328.00 | $410.00 | $73.80 – $222.83 | 17 |
| Mayo a1app alpha 1 antitrypsin phenotype CPT 82104 | $60.00 | $75.00 | $14.46 – $65.65 | 25 |
| Mayo aathr protein s free CPT 85306 | $115.20 | $144.00 | $15.32 – $99.73 | 25 |
| Mayo adalimumab (humira) therapeutic drug level CPT 80145 | $117.60 | $147.00 | $26.46 – $175.11 | 21 |
| Mayo alkaline phosphatase isoenzyme CPT 84080 | $61.60 | $77.00 | $13.86 – $67.10 | 20 |
| Mayo alpha 1 antitrypsin CPT 82103 | $56.00 | $70.00 | $13.44 – $61.02 | 25 |
| Mayo amikacin trough therapeutic drug level CPT 80150 | $62.40 | $78.00 | $13.75 – $68.46 | 25 |
| Mayo analysis gene jak2 p.val617phe variant CPT 81270 | $380.80 | $476.00 | $91.66 – $416.14 | 23 |
| Mayo androstenedione CPT 82157 | $121.60 | $152.00 | $29.28 – $132.93 | 25 |
| Mayo angiotensin 1 converting enzyme (ace) csf CPT 82164 | $60.80 | $76.00 | $14.60 – $68.58 | 25 |
| Mayo aspergillus fumigatus antibody CPT 86606 | $62.40 | $78.00 | $15.05 – $70.72 | 25 |
| Mayo avwpr vw factor activity CPT 85397 | $174.40 | $218.00 | $30.86 – $140.10 | 25 |
| Mayo babpb infectious agent nucleic acid amplified probe babesia microti CPT 87469 | $162.40 | $203.00 | $35.09 – $159.31 | 25 |
| Mayo bart bartonella henselae antibody igg CPT 86611 | $42.40 | $53.00 | $10.18 – $46.22 | 25 |
| Mayo blastomyces antibody immunodiffusion CPT 86612 | $64.00 | $80.00 | $12.90 – $60.62 | 25 |
| Mayo brcmg brucella antibody igm CPT 86622 | $37.60 | $47.00 | $8.93 – $53.23 | 25 |
| Mayo carnitine total and free quantitative each specimen plasma CPT 82379 | $69.60 | $87.00 | $15.66 – $76.59 | 20 |
| Mayo cdcom hla class ii typing low resolution one locus each CPT 81376 | $508.00 | $635.00 | $122.22 – $554.88 | 24 |
| Mayo ceruloplasmin CPT 82390 | $44.80 | $56.00 | $10.74 – $48.76 | 25 |
| Mayo chemiluminescent parathyroid related peptide CPT 82397 | $59.20 | $74.00 | $13.32 – $64.10 | 20 |
| Mayo chikv chikungunya antibodies igg CPT 86790 | $53.60 | $67.00 | $9.66 – $58.48 | 21 |
| Mayo chlap chlamydia pneumoniae antibody igg CPT 86631 | $48.80 | $61.00 | $11.82 – $56.89 | 25 |
| Mayo chlap chlamydia pneumoniae antibody igm CPT 86632 | $52.80 | $66.00 | $12.68 – $82.61 | 25 |
| Mayo chrcb tissue culture non-neoplastic disorders lymphocyte CPT 88230 | $581.60 | $727.00 | $95.88 – $547.40 | 25 |
| Mayo chromium CPT 82495 | $84.00 | $105.00 | $7.50 – $92.07 | 25 |
| Mayo coccidioides antibody CPT 86635 | $57.60 | $72.00 | $11.47 – $74.68 | 25 |
| Mayo cocou cortisone urine CPT 82542 | $100.00 | $125.00 | $24.09 – $109.37 | 25 |
| Mayo cortisol free CPT 82530 | $69.60 | $87.00 | $16.71 – $79.39 | 25 |
| Mayo covid-19 antibody nucleocapsid total CPT 86769 | $140.00 | $175.00 | $13.95 – $191.27 | 25 |
| Mayo coxiella brunetii (q fever) igg antibody CPT 86638 | $50.40 | $63.00 | $12.12 – $75.61 | 25 |
| Mayo deoxyribonuclease antibody titer CPT 86215 | $66.40 | $83.00 | $13.25 – $86.27 | 25 |
| Mayo dhea (dehydroepiandrosterone) CPT 82626 | $104.80 | $131.00 | $25.27 – $114.73 | 25 |
| Mayo dihydrotestosterone CPT 82642 | $121.60 | $152.00 | $11.95 – $132.93 | 21 |
| Mayo estrone CPT 82679 | $124.80 | $156.00 | $16.25 – $113.27 | 25 |
| Mayo ethosuximide therapeutic drug level CPT 80168 | $68.00 | $85.00 | $16.25 – $74.18 | 25 |
| Mayo everolimus therapeutic drug level CPT 80169 | $57.60 | $72.00 | $13.73 – $62.33 | 25 |
| Mayo factor ii CPT 85210 | $54.40 | $68.00 | $5.00 – $58.93 | 25 |
| Mayo factor v CPT 85220 | $132.80 | $166.00 | $6.25 – $80.13 | 25 |
| Mayo factor viii vw factor antigen CPT 85246 | $172.00 | $215.00 | $22.94 – $107.81 | 25 |
| Mayo factor viii vw factor multimetric analysis CPT 85247 | $628.80 | $786.00 | $22.94 – $107.81 | 25 |
| Mayo factor viii vw factor ristocetin cofactor CPT 85245 | $172.00 | $215.00 | $22.94 – $107.81 | 25 |
| Mayo factor xi CPT 85270 | $127.20 | $159.00 | $15.00 – $81.27 | 25 |
| Mayo fbl culture fungi blood CPT 87103 | $84.80 | $106.00 | $15.58 – $92.89 | 25 |
| Mayo ffspg allergen clam igg CPT 86001 | $32.80 | $41.00 | $7.23 – $35.50 | 25 |
| Mayo gabapentin bld/srm/plasma therapeutic drug level CPT 80171 | $81.60 | $102.00 | $18.09 – $98.38 | 25 |
| Mayo hip12 infectious agent nucleic acid amplified probe hiv-1 rna qualitative CPT 87535 | $145.60 | $182.00 | $32.76 – $159.31 | 20 |
| Mayo hip12 infectious agent nucleic acid amplified probe hiv-2 CPT 87538 | $145.60 | $182.00 | $26.32 – $159.31 | 21 |
| Mayo hiser histoplasma antibodies immunodiffusion CPT 86698 | $68.80 | $86.00 | $13.79 – $62.61 | 25 |
| Mayo hla typing a/b/c single antigen CPT 86812 | $107.20 | $134.00 | $15.00 – $117.18 | 25 |
| Mayo hvdip HIV 1 antibody CPT 86701 | $36.80 | $46.00 | $8.89 – $41.21 | 25 |
| Mayo hvdip HIV 2 antibody CPT 86702 | $56.80 | $71.00 | $13.52 – $61.38 | 25 |
| Mayo hydroxyprogesterone 17-d CPT 83498 | $112.80 | $141.00 | $25.63 – $123.35 | 25 |
| Mayo immunoassay c1 esterase inhibitor antibody quantitative CPT 83520 | $71.20 | $89.00 | $16.02 – $78.41 | 20 |
| Mayo immunoassay infectious agent antibody quantitative diptheria igg CPT 86317 | $62.40 | $78.00 | $14.99 – $97.59 | 25 |
| Mayo immunoassay tumor antigen quantitative ca 27.29 CPT 86300 | $85.00 | $108.00 | $20.81 – $135.44 | 25 |
| Mayo immunoassay tumor antigen quantitative chromogranin a CPT 86316 | $86.40 | $108.00 | $20.81 – $135.44 | 25 |
| Mayo infectious agent antigen immunoassay direct optical observation cryptococcus CPT 87899 | $66.40 | $83.00 | $12.05 – $72.96 | 21 |
| Mayo infectious agent antigen immunoassay ql/sq multi step aspergillus bal CPT 87305 | $49.60 | $62.00 | $11.98 – $71.69 | 25 |
| Mayo infectious agent nucleic acid amplified probe enterovirus CPT 87498 | $145.60 | $182.00 | $34.75 – $159.31 | 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.