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 |
|---|---|---|---|---|
| Pt wheelchair management each 15 minutes CPT 97542 | $98.40 | $123.00 | $29.62 – $56.80 | 20 |
| Pulse ox continuous overnight monitoring CPT 94762 | $180.80 | $226.00 | $40.68 – $270.46 | 16 |
| Pulse ox multiple CPT 94761 | $109.60 | $137.00 | $4.83 – $13.12 | 7 |
| Puncture arterial withdrawal blood for diagnosis CPT 36600 | $391.20 | $489.00 | $16.25 – $1,131.20 | 22 |
| Puncture aspiration abscess/hematoma/bulla/cyst CPT 10160 | $634.40 | $793.00 | $30.00 – $1,131.20 | 22 |
| Puncture spinal lumbar diagnostic CPT 62270 | $1,392.00 | $1,740.00 | $52.50 – $2,402.40 | 22 |
| Pyridoxine hcl 100 mg HCPCS J3415 | $131.60 | $164.50 | $4.59 – $44.00 | 10 |
| Pyruvate CPT 84210 | $60.00 | $75.00 | $10.00 – $65.74 | 25 |
| Quest t3 uptake CPT 84479 | $26.40 | $33.00 | $6.47 – $30.43 | 25 |
| Rabies ig ht&sol human im/sc CPT 90377 | $1,850.40 | $2,313.00 | $25.00 – $2,795.52 | 26 |
| Radiation physics consult CPT 77336 | $1,205.60 | $1,507.00 | $61.25 – $270.45 | 22 |
| Radiation therapy dose plan CPT 77300 | $1,205.60 | $1,507.00 | $45.63 – $229.51 | 22 |
| Radiation treatment aid(s) CPT 77334 | $2,071.20 | $2,589.00 | $114.38 – $632.82 | 22 |
| Radiation treatment delivery CPT 77412 | $1,540.80 | $1,926.00 | $55.00 – $454.62 | 22 |
| Radiology port images(s) CPT 77417 | $673.60 | $842.00 | $16.15 – $69.92 | 8 |
| Radiotherapy dose plan imrt CPT 77301 | $8,673.60 | $10,842.00 | $21.52 – $3,673.39 | 22 |
| Radphm lcl tmr plnr bdy sgl day img CPT 78802 | $4,720.00 | $5,900.00 | $137.48 – $7,779.35 | 23 |
| Radphm lcl tmr plnr bdy two day img CPT 78804 | $4,720.00 | $5,900.00 | $447.83 – $7,779.35 | 23 |
| Radphm lcl tomogr sgl area sgl day CPT 78803 | $4,720.00 | $5,900.00 | $272.87 – $7,779.35 | 23 |
| Radphm lcl tumor plr sgl day CPT 78800 | $1,713.60 | $2,142.00 | $107.20 – $2,259.58 | 23 |
| Rasburicase 1.5 mg intravenous solution HCPCS J2783 | $4,331.80 | $5,414.75 | $409.57 – $3,889.83 | 25 |
| Rbc count only automated CPT 85041 | $12.80 | $16.00 | $3.02 – $19.62 | 25 |
| Red blood cells leukocytes reduced each unit HCPCS P9016 | $1,181.60 | $1,477.00 | $37.50 – $318.50 | 21 |
| Red blood cells leukocytes reduced irradiated each unit HCPCS P9040 | $1,409.60 | $1,762.00 | $37.50 – $447.65 | 21 |
| Regadenoson 0.4 mg/5 ml intravenous syringe HCPCS J2785 | $119.20 | $149.00 | $3.27 – $61.74 | 10 |
| Relieve bladder contracture CPT 52640 | not published | not published | $1,101.92 – $10,305.03 | 3 |
| Relocation skin pocket aicd CPT 33223 | $7,968.00 | $9,960.00 | $1,806.95 – $6,420.00 | 17 |
| Remdesivir 100 mg intravenous powder for solution HCPCS J0248 | $7,576.00 | $9,470.00 | $7.30 – $2,250.18 | 25 |
| Rem endovas vena cava filter CPT 37193 | $5,162.40 | $6,453.00 | $369.78 – $7,441.00 | 2 |
| Removal biliary drg cath CPT 47537 | $1,539.20 | $1,924.00 | $101.28 – $2,448.60 | 22 |
| Removal central venous catheter tunneled without port/pump CPT 36589 | $2,853.60 | $3,567.00 | $162.94 – $2,402.40 | 22 |
| Removal central venous device tunneled w/port/pump central/peripheral insertion CPT 36590 | $2,996.00 | $3,745.00 | $230.11 – $4,641.46 | 9 |
| Removal cerclage without anes CPT 59899 | $192.80 | $241.00 | $43.38 – $1,131.20 | 18 |
| Removal cerumen impacted (both sides) CPT 69210 | $280.80 | $351.00 | $25.00 – $102.69 | 21 |
| Removal foreign body foot subcutaneous right CPT 28190 | $1,405.60 | $1,757.00 | $38.13 – $2,448.60 | 22 |
| Removal of breast lesion CPT 19120 | not published | not published | $1,101.92 – $11,441.35 | 3 |
| Removal of toe lesions CPT 28108 | not published | not published | $1,101.92 – $6,066.00 | 3 |
| Removal of urethra lesion CPT 53230 | not published | not published | $1,101.92 – $15,189.14 | 3 |
| Removal/replacement ppm generator dual lead system CPT 33228 | $33,458.40 | $41,823.00 | $6,420.00 – $28,500.00 | 3 |
| Removal skin tags fibrocutaneous any area <= 15 lesions CPT 11200 | not published | not published | $394.66 – $1,209.00 | 17 |
| Removal tunnled intprtnl cath CPT 49422 | $5,223.20 | $6,529.00 | $418.65 – $6,066.00 | 8 |
| Remove anal fist subq CPT 46270 | not published | not published | $1,101.92 – $8,193.88 | 3 |
| Remove hip/pelvis lesion 27047 CPT 27047 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Remove pilonidal cyst compl CPT 11772 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Remove pilonidal cyst exten CPT 11771 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Remove renal tube w/fluoro CPT 50389 | $1,152.00 | $1,440.00 | $56.48 – $2,448.60 | 8 |
| Remove/replace penis prosth CPT 54410 | not published | not published | $1,101.92 – $60,141.29 | 3 |
| Remove/replace ur sphincter CPT 53447 | not published | not published | $1,101.92 – $60,141.29 | 3 |
| Remove skin nerve lesion 64788 CPT 64788 | not published | not published | $1,101.92 – $6,066.00 | 3 |
| Renal function panel CPT 80069 | $36.00 | $45.00 | $8.68 – $39.41 | 25 |
| Renal venogram bil s&i CPT 75833 | $6,960.00 | $8,700.00 | $46.88 – $17,462.81 | 9 |
| Repair biceps tendon CPT 23430 | not published | not published | $1,101.92 – $54,946.88 | 3 |
| Repair complex wound scalp/arms/legs 2.6 - 7.5 cm CPT 13121 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Repair finger tendon CPT 26433 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Repair/graft achilles tendon CPT 27652 | not published | not published | $1,101.92 – $28,500.00 | 3 |
| Repair lip full thkns =<one-half vert height CPT 40652 | $1,976.80 | $2,471.00 | $384.10 – $2,448.60 | 22 |
| Repair nonunion hand CPT 26546 | not published | not published | $1,101.92 – $21,344.46 | 3 |
| Repair rectum & vagina CPT 57250 | not published | not published | $1,101.92 – $14,749.41 | 3 |
| Repair rpr lip full thickness vermilion only CPT 40650 | $1,601.60 | $2,002.00 | $311.16 – $2,448.60 | 22 |
| Repair tongue lac <2.5cm past 1/3 tongue 41251 CPT 41251 | $390.40 | $488.00 | $39.38 – $2,402.40 | 22 |
| Repair upper arm/elbow tendon/muscle ea CPT 24341 | not published | not published | $1,101.92 – $21,344.46 | 3 |
| Repair uro sphincter CPT 53449 | not published | not published | $1,101.92 – $27,629.18 | 3 |
| Replace duod/jej tube perc CPT 49451 | $1,540.00 | $1,925.00 | $87.91 – $2,402.40 | 22 |
| Replace g/c tube perc CPT 49450 | $1,808.80 | $2,261.00 | $63.88 – $2,402.40 | 22 |
| Replace g-j tube perc CPT 49452 | $1,558.40 | $1,948.00 | $137.23 – $2,402.40 | 22 |
| Reposition pm/icd lead CPT 33215 | $9,317.60 | $11,647.00 | $3,147.50 – $6,420.00 | 3 |
| Rerepair ing hernia blocked CPT 49521 | not published | not published | $1,101.92 – $18,643.49 | 3 |
| Respirator motion mgmt simul CPT 77293 | $985.60 | $1,232.00 | $71.84 – $1,100.00 | 8 |
| Resuscitation cardiopulmonary CPT 92950 | $889.60 | $1,112.00 | $200.16 – $1,131.20 | 18 |
| Reticulated platelet assay CPT 85055 | $220.80 | $276.00 | $35.74 – $162.26 | 25 |
| Reticulocyte direct measurement automated CPT 85046 | $42.40 | $53.00 | $5.57 – $25.29 | 25 |
| Revise breast reconst 19380 CPT 19380 | not published | not published | $1,101.92 – $19,485.21 | 3 |
| Revision of bladder neck CPT 52500 | not published | not published | $1,101.92 – $10,305.03 | 3 |
| Revision of testis CPT 54660 | not published | not published | $1,101.92 – $15,189.14 | 3 |
| Rev/rmv prph sac/gstr npg/r CPT 64595 | not published | not published | $1,101.92 – $10,275.27 | 3 |
| Rheumatoid factor quantitative CPT 86431 | $23.20 | $29.00 | $5.67 – $36.96 | 25 |
| Rho d immune globulin inj HCPCS J2790 | $330.40 | $413.00 | $62.71 – $276.13 | 5 |
| Rmvl icd by tv extr CPT 33244 | $7,868.00 | $9,835.00 | $3,594.97 – $6,420.00 | 17 |
| Rmvl icd gen w/rplc icd gen dual lead sys CPT 33263 | $49,040.00 | $61,300.00 | $6,420.00 – $28,500.00 | 3 |
| Rmvl icd gen w/rplc icd gen mlt lead sys CPT 33264 | $64,808.00 | $81,010.00 | $6,420.00 – $32,061.58 | 3 |
| Rmvl icd gen w/rplc icd gen sgl lead sys CPT 33262 | $19,912.00 | $24,890.00 | $6,420.00 – $28,500.00 | 3 |
| Rmvl icd pulse gen only CPT 33241 | $11,155.20 | $13,944.00 | $3,594.97 – $6,420.00 | 17 |
| Rmvl ndwellg tun pleural cath CPT 32552 | $1,156.80 | $1,446.00 | $160.21 – $1,131.20 | 18 |
| Rmvl perm pm pulse gen CPT 33233 | $9,761.60 | $12,202.00 | $6,066.00 – $8,275.98 | 3 |
| Rmvl pm gen w/rplc pm gen mlt lead sys CPT 33229 | $33,458.40 | $41,823.00 | $6,420.00 – $28,500.00 | 3 |
| Rmvl pm gen w/rplc pm gen sgl lead sys CPT 33227 | $30,504.80 | $38,131.00 | $6,420.00 – $26,645.50 | 3 |
| Rmvl subq card rhythm mntr CPT 33286 | $3,167.20 | $3,959.00 | $695.02 – $6,420.00 | 17 |
| Rmvl tv pm lead dual CPT 33235 | $27,104.80 | $33,881.00 | $3,594.97 – $6,420.00 | 17 |
| Rmvl tv pm lead sgl CPT 33234 | $15,964.80 | $19,956.00 | $3,594.97 – $6,420.00 | 17 |
| Ropivacaine 0.2 % epidural pca - 1 hour dose limit HCPCS J2795 | $222.80 | $278.50 | $0.05 – $4.20 | 10 |
| Rpl non-tun cvc wo sbq prt/pmp CPT 36580 | $3,220.00 | $4,025.00 | $80.60 – $4,109.00 | 2 |
| Rp loclzj tum spect w/ct 1 CPT 78830 | $4,720.00 | $5,900.00 | $406.85 – $7,779.35 | 23 |
| Rp loclzj tum spect w/ct 2 CPT 78832 | $5,280.00 | $6,600.00 | $797.45 – $8,570.95 | 23 |
| Rpl picc wo subq port/pump incl image guidnc w/s&i CPT 36584 | $727.20 | $909.00 | $81.43 – $4,109.00 | 8 |
| Rpl tun cvc wo subq port CPT 36581 | $4,105.60 | $5,132.00 | $232.36 – $6,956.60 | 8 |
| Rubella antibody igg CPT 86762 | $60.00 | $75.00 | $14.39 – $93.71 | 25 |
| Rubeola antibody igg CPT 86765 | $53.60 | $67.00 | $12.88 – $63.75 | 25 |
| Russell viper venom diluted CPT 85613 | $72.00 | $90.00 | $9.58 – $62.28 | 25 |
| Scan duplex abd/pelvis/retroperitoneal complete CPT 93975 | $857.60 | $1,072.00 | $228.06 – $620.33 | 21 |
| Scan duplex abd/pelvis/retroperitoneal limited CPT 93976 | $857.60 | $1,072.00 | $105.04 – $445.40 | 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.