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 |
|---|---|---|---|---|
| Mumps antibody igg CPT 86735 | $54.40 | $68.00 | $12.24 – $68.91 | 20 |
| Muscle-skin graft trunk CPT 15734 | not published | not published | $1,101.92 – $18,643.49 | 3 |
| Muscle test cran nerv unilat CPT 95867 | $309.60 | $387.00 | $31.25 – $538.32 | 21 |
| Mycophenolate mofetil 250 mg capsule HCPCS J7517 | $2,490.00 | $3,112.50 | $0.12 – $0.53 | 10 |
| Mycophenolic acid HCPCS J7518 | $24.20 | $30.25 | $0.26 – $1.33 | 10 |
| Mycoplasma antibody igm CPT 86738 | $55.20 | $69.00 | $13.24 – $61.95 | 25 |
| Myeloperoxidase ab multi step qualitative/semiquantitative CPT 83516 | $48.00 | $60.00 | $8.65 – $52.35 | 21 |
| Nafcillin 2 gram solution for injection HCPCS J2290 | $277.00 | $346.25 | $0.06 – $38.50 | 10 |
| Naloxone 0.4 mg/ml injection (wrapper) HCPCS J2312 | $469.60 | $587.00 | $0.08 – $1.00 | 9 |
| Natriuretic peptide CPT 83880 | $80.00 | $204.00 | $39.26 – $178.24 | 25 |
| Natural killer cells total count CPT 86357 | $157.60 | $197.00 | $37.73 – $171.29 | 25 |
| N block inj hypogas plxs CPT 64517 | $1,278.40 | $1,598.00 | $131.21 – $2,448.60 | 22 |
| Neck (Cervical Spine) CT scan (with contrast) CPT 72126 | $472.00 | $2,350.00 | $188.19 – $2,106.92 | 24 |
| Neck (Cervical Spine) CT scan (without contrast) CPT 72125 | $282.00 | $1,610.00 | $105.04 – $602.31 | 24 |
| Neck (Cervical Spine) MRI (with and without contrast) CPT 72156 | $701.50 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| Neck (Cervical Spine) MRI (with contrast) CPT 72142 | $633.50 | $2,350.00 | $352.78 – $2,106.92 | 24 |
| Neck (Cervical Spine) MRI (without contrast) CPT 72141 | $454.00 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| Neck MRA (blood vessel MRI, with and without contrast) CPT 70549 | $735.00 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| Neck MRA (blood vessel MRI, without contrast) CPT 70547 | $473.00 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| Nerve conduction 7-8 studies CPT 95910 | $1,476.00 | $1,845.00 | $174.83 – $538.32 | 21 |
| Nerve conduction studies 11-12 CPT 95912 | $2,188.00 | $2,735.00 | $248.41 – $917.25 | 21 |
| Nerve conduction studies 13+ CPT 95913 | $2,754.40 | $3,443.00 | $288.19 – $917.25 | 21 |
| Nerve conduction studies 3-4 CPT 95908 | $771.20 | $964.00 | $110.75 – $538.32 | 21 |
| Nerve conduction studies 5-6 CPT 95909 | $1,035.20 | $1,294.00 | $132.75 – $538.32 | 21 |
| Nerve conduction studies 9-10 CPT 95911 | $1,788.00 | $2,235.00 | $211.93 – $917.25 | 21 |
| Neurolysis celiac plexus CPT 64680 | $2,448.00 | $3,060.00 | $91.88 – $4,109.00 | 22 |
| Neuromuscular junction testing ea nerve any 1 method CPT 95937 | $82.40 | $103.00 | $24.66 – $270.46 | 21 |
| New Patient Office Visit (level 3) CPT 99203 | $239.20 | $299.00 | $50.00 – $222.78 | 21 |
| New Patient Office Visit (level 4) CPT 99204 | $388.80 | $486.00 | $50.00 – $222.78 | 21 |
| New Patient Office Visit (level 5) CPT 99205 | $413.60 | $517.00 | $50.00 – $222.78 | 20 |
| Nicardipine 25 mg/10 ml intravenous solution HCPCS J2404 | $332.40 | $415.50 | $0.08 – $3.15 | 10 |
| Nitroglycerin 50 mg/250 ml (200 mcg/ml) in 5 % dextrose intravenous HCPCS J2305 | $286.20 | $357.75 | $1.13 – $4.97 | 10 |
| Nm imaging bone/joint 3 phase study CPT 78315 | $1,713.60 | $2,142.00 | $207.96 – $2,259.58 | 23 |
| Nm imaging bone/joint whole body CPT 78306 | $1,713.60 | $2,142.00 | $126.85 – $2,259.58 | 23 |
| Nm imaging cardiac blood pooling planar single study at rest or stress CPT 78472 | $1,713.60 | $2,142.00 | $127.50 – $2,259.58 | 23 |
| Nm imaging gastric emptying study CPT 78264 | $1,713.60 | $2,142.00 | $168.74 – $2,259.58 | 23 |
| Nm imaging gastrointestinal acute blood loss CPT 78278 | $1,713.60 | $2,142.00 | $80.00 – $2,259.58 | 23 |
| Nm imaging hepatobiliary system w/pharmacologic intervention CPT 78227 | $2,225.60 | $2,782.00 | $372.27 – $2,961.19 | 23 |
| Nm imaging kidney morphology vascular flow/function single study w/pharmacological intervention CPT 78708 | $2,225.60 | $2,782.00 | $122.06 – $2,961.19 | 23 |
| Nm imaging pulmonary ventilation/perfusion CPT 78582 | $2,225.60 | $2,782.00 | $248.51 – $2,961.19 | 23 |
| Nm imaging thyroid single/multiple uptake(s) quantitative measurement(s) CPT 78014 | $1,713.60 | $2,142.00 | $199.95 – $2,259.58 | 23 |
| Nr lnr acclrtr tx max 5 sessions CPT 77373 | $4,364.80 | $5,456.00 | $628.54 – $3,400.00 | 22 |
| Ntsty modul rad tx dlvr cplx CPT 77386 | $4,231.20 | $5,289.00 | $355.61 – $999.99 | 21 |
| Ntsty modul rad tx dlvr smpl CPT 77385 | $4,231.20 | $5,289.00 | $336.00 – $999.99 | 21 |
| Nuclear Stress Test (Heart) CPT 78452 | $6,240.00 | $7,800.00 | $278.10 – $7,779.35 | 23 |
| Observation direct referral from physician office for admission HCPCS G0379 | $156.80 | $196.00 | $35.28 – $1,059.85 | 17 |
| Obstetric panel inc HIV tstg CPT 80081 | $230.00 | $389.00 | $74.86 – $339.86 | 25 |
| Obstetrics panel CPT 80055 | $190.00 | $249.00 | $15.00 – $217.06 | 24 |
| Octreotide acetate 100 mcg/ml injection (wrapper) HCPCS J2354 | $88.20 | $110.25 | $0.66 – $4.13 | 10 |
| Olanzapine 10 mg intramuscular solution HCPCS J2359 | $177.20 | $221.50 | $0.95 – $65.10 | 10 |
| Ondansetron hcl (pf) 2 mg/ml injection (wrapper) HCPCS J2405 | $75.20 | $94.00 | $0.10 – $10.78 | 10 |
| Organic acids total quant ea spec CPT 83918 | $98.40 | $123.00 | $23.60 – $107.14 | 25 |
| Ortho dvc repair per 15 min HCPCS L4205 | $158.40 | $198.00 | $30.02 – $52.54 | 17 |
| Ortho ewh rgd without jnt cstm w/fit&adj HCPCS L3763 | $157.60 | $197.00 | $221.50 – $1,314.69 | 16 |
| Ortho hnd/fngr without jnt cstm w/fit&adj HCPCS L3913 | $148.00 | $185.00 | $220.43 – $507.26 | 16 |
| Ortho hnd/fngr w/jnt cstm w/fit&adj HCPCS L3921 | $283.20 | $354.00 | $294.16 – $601.62 | 16 |
| Ortho whf rigd without jnt cstm w/fit&adj HCPCS L3808 | $152.80 | $191.00 | $210.51 – $700.39 | 16 |
| Oscillation chest wall mechanical per session CPT 94669 | $566.40 | $708.00 | $127.44 – $351.59 | 17 |
| Osmolality blood CPT 83930 | $27.20 | $34.00 | $3.75 – $30.01 | 25 |
| Osmolality urine CPT 83935 | $28.00 | $35.00 | $3.75 – $30.96 | 25 |
| Ot evaluation high complexity patient/family CPT 97167 | $319.20 | $399.00 | $77.16 – $209.88 | 21 |
| Ot evaluation low complexity patient/family CPT 97165 | $335.20 | $419.00 | $77.16 – $209.88 | 21 |
| Ot evaluation moderate complexity patient/family CPT 97166 | $319.20 | $399.00 | $77.16 – $209.88 | 21 |
| Oth resp proc, group HCPCS G0239 | $288.80 | $361.00 | $38.77 – $67.85 | 19 |
| Oth resp proc, indiv HCPCS G0238 | $140.00 | $175.00 | $18.37 – $42.33 | 17 |
| Ot management orthotic(s)/prosthetic subsequent encounter each 15 minutes CPT 97763 | $148.80 | $186.00 | $47.61 – $83.32 | 20 |
| Ot management/training orthotic(s) upper/lower extremities and/or trunk each 15 minutes CPT 97760 | $144.80 | $181.00 | $43.76 – $76.58 | 20 |
| Ot manual therpy techniques >=1 region each 15 minutes CPT 97140 | $219.20 | $274.00 | $26.20 – $136.00 | 21 |
| Ot re-evaluation patient/family CPT 97168 | $206.40 | $258.00 | $50.86 – $138.35 | 21 |
| Ot therapeutic activities direct patient contact each 15 minutes CPT 97530 | $214.40 | $268.00 | $33.12 – $136.00 | 21 |
| Ot therapeutic interventions cognitive skills direct patient contact each additional 15 minutes CPT 97130 | $154.40 | $193.00 | $20.32 – $136.00 | 21 |
| Ot therapeutic interventions cognitive skills direct patient contact initial 15 minutes CPT 97129 | $154.40 | $193.00 | $20.97 – $136.00 | 20 |
| Ot therapeutic procedure >=1 area therapeutic exercise each 15 minutes CPT 97110 | $204.00 | $255.00 | $27.75 – $136.00 | 21 |
| Ot therapeutic procedure neuromuscular reeducate each 15 minutes CPT 97112 | $200.00 | $250.00 | $30.87 – $136.00 | 21 |
| Ot training self care/home management direct contact each 15 minutes CPT 97535 | $144.80 | $181.00 | $30.75 – $56.80 | 20 |
| Palonosetron hcl HCPCS J2469 | $115.40 | $144.25 | $0.39 – $16.80 | 10 |
| Parathormone (pth) intact CPT 83970 | $171.20 | $214.00 | $41.28 – $187.41 | 25 |
| Parathyrd planar w/spect&ct CPT 78072 | $2,225.60 | $2,782.00 | $399.23 – $2,961.19 | 22 |
| Parathyroid planar img w/tomo spect CPT 78071 | $1,713.60 | $2,142.00 | $278.85 – $2,259.58 | 23 |
| Paring/cutting benign hyperkeratotic lesion single CPT 11055 | $300.00 | $375.00 | $25.00 – $1,131.20 | 22 |
| Part hymenectomy/revi hymenal ring 56700 CPT 56700 | not published | not published | $1,101.92 – $9,499.98 | 3 |
| Partial removal finger bone CPT 26235 | not published | not published | $1,101.92 – $4,781.81 | 3 |
| Part removal of metatarsal CPT 28110 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Passy muir valve metal trach HCPCS L8501 | $97.60 | $122.00 | $93.75 – $253.73 | 16 |
| Pelvic CT scan (with and without contrast) CPT 72194 | $572.00 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| Pelvic CT scan (with contrast) CPT 72193 | $475.50 | $2,362.00 | $175.11 – $1,006.60 | 24 |
| Pelvic CT scan (without contrast) CPT 72192 | $281.00 | $1,610.00 | $105.04 – $602.31 | 24 |
| Pelvic MRI (with and without contrast) CPT 72197 | $706.00 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| Pelvic MRI (without contrast) CPT 72195 | $455.50 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| Pelvic Ultrasound (complete) CPT 76856 | $517.60 | $647.00 | $58.13 – $602.31 | 23 |
| Pelvic Ultrasound (limited) CPT 76857 | $468.00 | $585.00 | $40.00 – $602.31 | 24 |
| Penicillin g benzathine 1,200,000 unit/2 ml intramuscular syringe HCPCS J0561 | $2,656.00 | $3,320.00 | $32.56 – $1,204.28 | 25 |
| Penicillin g potassium in ns IV syringe 100,000 units/ml (neo/ped) - cnr HCPCS J2540 | $191.40 | $239.25 | $0.86 – $14.08 | 10 |
| Penile injection CPT 54235 | $490.40 | $613.00 | $110.34 – $1,131.20 | 18 |
| Pericardiocentesis wwo imaging CPT 33016 | $2,207.20 | $2,759.00 | $242.41 – $6,066.00 | 8 |
| Perineoplasty rpr per nonob CPT 56810 | not published | not published | $1,101.92 – $9,499.98 | 3 |
| Pet CT skull-mid thgh initial CPT 78815 | $6,880.00 | $8,600.00 | $972.09 – $8,570.95 | 23 |
| Pet CT whole body initial CPT 78816 | $6,880.00 | $8,600.00 | $972.09 – $8,570.95 | 23 |
| Pet fdg brain metoblic eval sb CPT 78608 | $5,280.00 | $6,600.00 | $853.86 – $8,570.95 | 23 |
| Ph body fluid CPT 83986 | $15.20 | $19.00 | $2.50 – $16.25 | 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.