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 |
|---|---|---|---|---|
| Mayo infectious agent nucleic acid amplified probe mycoplasma genitalium urine CPT 87563 | $145.60 | $182.00 | $35.09 – $159.31 | 25 |
| Mayo infectious agent nucleic acid amplified probe mycoplasma pneumoniae CPT 87581 | $145.60 | $182.00 | $32.76 – $159.31 | 20 |
| Mayo infectious agent nucleic acid quantification cytomegalovirus CPT 87497 | $178.40 | $223.00 | $42.84 – $194.49 | 25 |
| Mayo infectious disease hepatitis c chronic six biochemical assays CPT 81596 | $300.00 | $375.00 | $11.95 – $327.74 | 25 |
| Mayo infliximab therapeutic drug level CPT 80230 | $117.60 | $147.00 | $12.81 – $175.11 | 20 |
| Mayo inhab inhibin a CPT 86336 | $64.80 | $81.00 | $14.58 – $70.78 | 20 |
| Mayo insulin antibodies CPT 86337 | $106.40 | $133.00 | $13.75 – $97.20 | 25 |
| Mayo lacosamide therapeutic drug level CPT 80235 | $82.40 | $103.00 | $18.54 – $123.08 | 20 |
| Mayo lamotrigine therapeutic drug level CPT 80175 | $55.20 | $69.00 | $13.25 – $60.16 | 25 |
| Mayo ld_i lactate dehydrogenase isoenzymes CPT 83625 | $53.60 | $67.00 | $12.79 – $58.07 | 25 |
| Mayo legionella antibody CPT 86713 | $64.00 | $80.00 | $15.30 – $70.89 | 25 |
| Mayo lywb borrelia burgdorferi (lyme disease) antibody igg confirmatory CPT 86617 | $64.00 | $80.00 | $15.49 – $100.80 | 25 |
| Mayo metanephrines plasma CPT 83835 | $70.40 | $88.00 | $16.25 – $76.91 | 25 |
| Mayo mgle voltage-gated calcium channel antibody each CPT 86596 | $76.80 | $96.00 | $12.05 – $65.31 | 25 |
| Mayo mgrm acetylcholine receptor binding antibody CPT 86041 | $76.80 | $96.00 | $18.40 – $66.83 | 23 |
| Mayo microsomal antibody liver-kidney CPT 86376 | $60.80 | $76.00 | $9.89 – $66.06 | 25 |
| Mayo mitotane (lysodren) therapeutic drug level CPT 80299 | $92.80 | $116.00 | $18.64 – $84.63 | 25 |
| Mayo molecular pathology procedure level 2 apoe genotype CPT 81401 | $569.60 | $712.00 | $128.16 – $621.98 | 20 |
| Mayo muramidase CPT 85549 | $94.40 | $118.00 | $18.75 – $85.13 | 25 |
| Mayo muscle-specific kinase (musk) antibody CPT 86366 | $76.80 | $96.00 | $13.80 – $60.79 | 19 |
| Mayo mycophenolic acid therapeutic drug level CPT 80180 | $89.60 | $112.00 | $18.05 – $81.95 | 25 |
| Mayo myoglobin CPT 83874 | $54.40 | $68.00 | $12.92 – $58.66 | 25 |
| Mayo organic acid methylmalonic single quantitative CPT 83921 | $88.00 | $110.00 | $21.21 – $96.29 | 25 |
| Mayo oxalate 24 hour urine CPT 83945 | $60.00 | $75.00 | $14.45 – $65.60 | 25 |
| Mayo parvs parvovirus b19 antibody igg CPT 86747 | $75.20 | $94.00 | $15.03 – $70.62 | 25 |
| Mayo paval fluorescent antibody screen agna type 1 CPT 86255 | $49.60 | $62.00 | $12.05 – $78.47 | 25 |
| Mayo pborb infectious agent nucleic acid amplified probe borrelia burgdorferi (lyme) CPT 87476 | $145.60 | $182.00 | $35.09 – $159.31 | 25 |
| Mayo phospholipid neutralization hexagonal lupus anticoagulant CPT 85598 | $120.80 | $151.00 | $17.98 – $82.65 | 25 |
| Mayo pntft phenytoin free therapeutic drug level CPT 80186 | $57.60 | $72.00 | $13.76 – $62.47 | 25 |
| Mayo pqnu porphobilinogen urine quantitative 24 hour urine CPT 84110 | $35.20 | $44.00 | $2.50 – $38.32 | 25 |
| Mayo pregnenolone CPT 84140 | $85.60 | $107.00 | $20.67 – $104.93 | 25 |
| Mayo prmb primidone therapeutic drug level CPT 80188 | $68.80 | $86.00 | $16.59 – $75.32 | 25 |
| Mayo proinsulin CPT 84206 | $110.40 | $138.00 | $10.00 – $121.17 | 25 |
| Mayo psaft prostate specific antigen free CPT 84154 | $45.00 | $96.00 | $18.39 – $83.49 | 25 |
| Mayo radioimmunoassay procollagen i intact n-terminal antibody quantitative CPT 83519 | $76.80 | $96.00 | $17.28 – $83.54 | 20 |
| Mayo receptor assay transferrin soluble CPT 84238 | $152.00 | $190.00 | $27.50 – $166.03 | 25 |
| Mayo renin CPT 84244 | $91.20 | $114.00 | $15.00 – $99.83 | 25 |
| Mayo repu protein electrophoresis urine CPT 84166 | $45.00 | $93.00 | $17.83 – $80.95 | 25 |
| Mayo selenium CPT 84255 | $106.40 | $133.00 | $19.15 – $115.91 | 21 |
| Mayo serotonin CPT 84260 | $128.80 | $161.00 | $30.98 – $140.65 | 25 |
| Mayo sfgp rickettsia rickettsii antibody igg CPT 86757 | $80.80 | $101.00 | $19.35 – $87.85 | 25 |
| Mayo sirolimus therapeutic drug level CPT 80195 | $57.60 | $72.00 | $13.73 – $62.33 | 25 |
| Mayo syphilis test non-treponemal antibody qualitative vdrl CPT 86592 | $17.60 | $22.00 | $4.27 – $27.78 | 25 |
| Mayo tcgr analysis gene rearrangement trb@ abnormal clonal population(s) amplification CPT 81340 | $869.60 | $1,087.00 | $40.65 – $948.50 | 20 |
| Mayo tgrp testosterone free CPT 84402 | $105.60 | $132.00 | $25.47 – $115.63 | 25 |
| Mayo tgrp testosterone total CPT 84403 | $107.20 | $134.00 | $25.81 – $117.18 | 25 |
| Mayo thiopurine s-methyltransferase CPT 84433 | $385.60 | $482.00 | $22.17 – $100.65 | 25 |
| Mayo thyroglobulin CPT 84432 | $66.40 | $83.00 | $16.06 – $73.98 | 25 |
| Mayo ticks anaplasma phagocytophilum antibody igg CPT 86666 | $50.40 | $63.00 | $10.18 – $66.21 | 25 |
| Mayo ticks babesia microti antibody igg CPT 86753 | $51.20 | $64.00 | $9.29 – $56.25 | 21 |
| Mayo valpg valproic acid free therapeutic drug level CPT 80165 | $56.80 | $71.00 | $13.54 – $61.47 | 25 |
| Mayo vasoactive intestinal peptide CPT 84586 | $147.20 | $184.00 | $35.33 – $166.02 | 25 |
| Mayo vitamin b-2 (riboflavin) CPT 84252 | $84.00 | $105.00 | $10.00 – $91.89 | 25 |
| Mayo vitamin b3 (niacin) CPT 84591 | $70.40 | $88.00 | $12.80 – $77.45 | 21 |
| Mayo vitamin k CPT 84597 | $57.60 | $72.00 | $12.96 – $62.29 | 20 |
| Mayo zonisamide therapeutic drug level CPT 80203 | $55.20 | $69.00 | $13.25 – $60.16 | 25 |
| Meropenem 1 gram intravenous solution HCPCS J2185 | $99.00 | $123.75 | $0.46 – $7.53 | 10 |
| Metabolic Blood Panel (Basic) CPT 80048 | $20.00 | $46.00 | $8.46 – $38.41 | 26 |
| Metabolic Blood Panel (Comprehensive) CPT 80053 | $25.00 | $57.00 | $10.56 – $47.94 | 26 |
| Metabolic panel ionized ca CPT 80047 | $60.00 | $75.00 | $12.36 – $56.70 | 24 |
| Methotrexate sodium 2.5 mg tablet HCPCS J8610 | $12.20 | $15.25 | $0.14 – $0.70 | 10 |
| Methotrexate sodium (pf) 1 gram solution for injection HCPCS J9260 | $137.40 | $171.75 | $2.14 – $9.42 | 10 |
| Methotrexate therapeutic drug level CPT 80204 | $83.20 | $104.00 | $18.72 – $175.11 | 22 |
| Methylene blue (antidote) 5 mg/ml intravenous solution HCPCS Q9968 | $1,176.20 | $1,470.25 | $10.29 – $628.80 | 21 |
| Methylergonovine 0.2 mg/ml (1 ml) injection solution HCPCS J2210 | $192.00 | $240.00 | $15.73 – $74.52 | 10 |
| Methylprednisolone 4 mg tablet HCPCS J7509 | $27.00 | $33.75 | $0.08 – $0.84 | 9 |
| Methylprednisolone acetate 40 mg/ml suspension for injection HCPCS J1010 | $161.60 | $202.00 | $0.13 – $15.92 | 24 |
| Methylprednisolone sodium succinate 1,000 mg intravenous solution HCPCS J2919 | $147.60 | $184.50 | $0.23 – $7.00 | 24 |
| Metoclopramide in d5w IV syringe 0.2 mg/ml (neo/ped) - cnr HCPCS J2765 | $67.60 | $84.50 | $0.83 – $3.96 | 10 |
| Metoprolol tartrate 5 mg/5 ml intravenous (wrapper) HCPCS J0616 | $51.40 | $64.25 | $0.13 – $2.08 | 9 |
| Metronidazole 500 mg/100 ml in sodium chlor(iso) intravenous piggyback HCPCS J1836 | $58.80 | $73.50 | $0.03 – $5.25 | 10 |
| Micafungin 100 mg intravenous solution HCPCS J2248 | $255.60 | $319.50 | $0.28 – $99.20 | 10 |
| Midazolam 1 mg/ml injection solution HCPCS J2250 | $69.20 | $86.50 | $0.17 – $2.56 | 10 |
| Milrinone 20 mg/100 ml(200 mcg/ml) in 5 % dextrose intravenous piggybk HCPCS J2260 | $376.60 | $470.75 | $1.58 – $21.98 | 10 |
| Minocycline hydrochloride HCPCS J2265 | $1,952.20 | $2,440.25 | $3.15 – $924.00 | 21 |
| Mitomycin 40 mg intravenous solution HCPCS J9280 | $1,374.20 | $1,717.75 | $22.08 – $361.86 | 25 |
| Mnpj anes sho jt fixj aprats CPT 23700 | not published | not published | $1,101.92 – $4,781.81 | 3 |
| Morphine 4 mg/ml injection (wrapper) HCPCS J2270 | $154.80 | $193.50 | $1.66 – $16.21 | 10 |
| Morphine 4 mg/ml injection (wrapper)|discarded drug not administered HCPCS J2272 | $27.00 | $33.75 | $6.64 – $29.25 | 10 |
| Morphine (pf) 0.25 mg/0.5 ml injection (neo/ped) - cnr HCPCS J2274 | $232.60 | $290.75 | $9.16 – $40.31 | 10 |
| Morphometric analysis in situ hybridization computer-assisted per specimen each multiplex stain CPT 88374 | $680.00 | $850.00 | $22.76 – $1,307.11 | 25 |
| Morphometric analysis tumor ihc qn/sq per specimen each single antibody stain computer-assisted CPT 88361 | $272.00 | $340.00 | $35.23 – $1,027.44 | 25 |
| Morphometric analysis tumor ihc qn/sq per specimen each single antibody stain manual CPT 88360 | $344.00 | $430.00 | $99.02 – $513.93 | 25 |
| M/phmtrc alys ishquant/semiq CPT 88377 | $234.40 | $293.00 | $128.42 – $1,709.54 | 25 |
| MRA abdomen post contrast CPT 74185 | $735.50 | $2,646.00 | $352.78 – $1,826.63 | 24 |
| MRI breast c-+ w/cad uni CPT 77048 | $680.00 | $2,600.00 | $352.78 – $1,395.12 | 24 |
| MRI breast without cont bi CPT 77047 | $448.85 | $2,225.00 | $166.34 – $1,342.45 | 24 |
| MRI breast w IV cont bi CPT 77049 | $705.34 | $2,600.00 | $352.78 – $1,381.96 | 24 |
| MRI chest without contrast CPT 71550 | $457.00 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| MRI chest without & w/contrast CPT 71552 | $706.00 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| MRI loex nonjt w IV cont CPT 73719 | $645.50 | $2,350.00 | $352.78 – $2,106.92 | 24 |
| MRI lower extremity other than joint without contrast (both sides) CPT 73718 | $463.00 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| MRI lower extremity other than joint without & w/contrast (both sides) CPT 73720 | $712.50 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| MRI orbit/face/neck without contrast CPT 70540 | $463.50 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| MRI orbit/face/neck without & w/contrast CPT 70543 | $713.00 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| MRI tmj CPT 70336 | $658.00 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| MRI upper extremity other than joint without contrast (both sides) CPT 73218 | $463.50 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| MRI upper extremity other than joint without & w/contrast (both sides) CPT 73220 | $712.50 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| Mthfr gene analy common variants CPT 81291 | $254.40 | $318.00 | $65.34 – $296.64 | 17 |
| Multiple sleep latency test CPT 95805 | $3,068.80 | $3,836.00 | $296.06 – $917.25 | 21 |
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.