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 |
|---|---|---|---|---|
| Scan duplex aorta/ivc/iliac or bypass grafts complete CPT 93978 | $642.40 | $803.00 | $152.44 – $417.87 | 21 |
| Scan duplex aorta/ivc/iliac unilateral/limited CPT 93979 | $303.20 | $379.00 | $105.04 – $339.15 | 21 |
| Scan duplex extracranial arteries unilateral/limited study CPT 93882 | $555.20 | $694.00 | $105.04 – $469.44 | 21 |
| Scan duplex extremity veins unilateral/limited study CPT 93971 | $863.20 | $1,079.00 | $105.04 – $339.32 | 21 |
| Scan duplex lower extremity arteries complete bilateral CPT 93925 | $1,215.20 | $1,519.00 | $183.51 – $499.15 | 21 |
| Scan duplex lower extremity arteries unilateral/limited study left CPT 93926 | $820.80 | $1,026.00 | $105.04 – $330.34 | 21 |
| Scan duplex upper extremity arteries unilateral/limited study left CPT 93931 | $824.00 | $1,030.00 | $105.04 – $317.70 | 21 |
| Sclerotherapy fluid collection pq w/img CPT 49185 | $980.00 | $1,225.00 | $220.50 – $4,396.00 | 3 |
| Scope plantar fasciotomy CPT 29893 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Scope uretscp lithovue dig disp HCPCS C1747 | $4,632.00 | $5,790.00 | $1,256.43 – $2,198.75 | 15 |
| Screening hepatitis b non-obstetric high risk HCPCS G0499 | $117.60 | $147.00 | $23.75 – $128.35 | 25 |
| Screening hepatitis c antibody high risk HCPCS G0472 | $108.80 | $136.00 | $23.75 – $210.43 | 24 |
| Screening Mammogram CPT 77067 | $225.00 | $427.00 | $83.06 – $521.53 | 24 |
| Screening prostate cancer PSA HCPCS G0103 | $45.00 | $101.00 | $19.31 – $87.67 | 25 |
| Sedimentation rate erythrocyte automated CPT 85652 | $20.00 | $25.00 | $2.70 – $20.00 | 26 |
| Semen analysis presence/motility CPT 89321 | $49.60 | $62.00 | $9.04 – $78.47 | 21 |
| Serpina1 gene CPT 81332 | $217.60 | $272.00 | $43.65 – $198.17 | 23 |
| Set radiation therapy field CPT 77280 | $1,745.60 | $2,182.00 | $75.00 – $229.51 | 22 |
| Set radiation therapy field CPT 77290 | $2,716.80 | $3,396.00 | $85.66 – $632.82 | 22 |
| Shoulder MRI (with and without contrast) CPT 73223 | $712.50 | $2,805.00 | $352.78 – $2,106.92 | 24 |
| Shoulder MRI (with contrast) CPT 73222 | $645.50 | $2,481.00 | $397.59 – $4,386.56 | 24 |
| Shoulder MRI (without contrast) CPT 73221 | $461.50 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| Shoulder X-ray CPT 73030 | $398.40 | $498.00 | $18.91 – $497.84 | 24 |
| Sickling rbc CPT 85660 | $36.00 | $45.00 | $3.75 – $33.44 | 25 |
| Sigmoidoscopy w/ablation CPT 45346 | not published | not published | $1,101.92 – $4,396.00 | 17 |
| Sigmoidoscopy w/resection CPT 45349 | not published | not published | $1,101.92 – $8,193.88 | 3 |
| Sincalide 5 mcg solution for injection HCPCS J2805 | $910.20 | $1,137.75 | $93.69 – $501.41 | 10 |
| Sinus CT scan (with and without contrast) CPT 70488 | $568.00 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| Sinus CT scan (with contrast) CPT 70487 | $494.00 | $2,362.00 | $167.50 – $1,006.60 | 24 |
| Sinus CT scan (without contrast) CPT 70486 | $295.00 | $1,610.00 | $105.04 – $602.31 | 24 |
| Sinus/juglr venogram s&i CPT 75860 | $6,960.00 | $8,700.00 | $31.25 – $17,462.81 | 9 |
| Skin Biopsy CPT 11102 | $617.60 | $772.00 | $40.29 – $1,209.00 | 22 |
| Sleep Study (Polysomnography) CPT 95810 | $3,935.20 | $4,919.00 | $433.20 – $1,758.75 | 21 |
| Sleeve fing rolyan med HCPCS L3933 | $316.80 | $396.00 | $67.93 – $399.56 | 16 |
| Small bowel endoscopy CPT 44369 | not published | not published | $1,101.92 – $5,667.92 | 3 |
| Small bowel endoscopy/biopsy CPT 44361 | not published | not published | $1,101.92 – $5,667.92 | 3 |
| Smear fluorescent and/or acid fast stain CPT 87206 | $22.40 | $28.00 | $3.75 – $30.27 | 25 |
| Smear gram stain CPT 87205 | $16.80 | $21.00 | $4.27 – $19.39 | 25 |
| Smear nasal eosinophil CPT 89190 | $28.80 | $36.00 | $5.79 – $30.90 | 25 |
| Smear special stain inclusion bodies/parasites CPT 87207 | $29.60 | $37.00 | $5.63 – $27.19 | 25 |
| Smear wet mount CPT 87210 | $24.00 | $30.00 | $5.82 – $27.78 | 25 |
| Sodium 24 hour urine CPT 84300 | $20.80 | $26.00 | $5.06 – $22.97 | 25 |
| Sodium chloride 0.9 % intravenous solution HCPCS J7030 | $37.20 | $46.50 | $1.48 – $8.65 | 9 |
| Sodium serum/plasma/whole blood CPT 84295 | $25.60 | $32.00 | $4.81 – $22.10 | 24 |
| Special physics consult CPT 77370 | $1,668.80 | $2,086.00 | $120.63 – $505.16 | 22 |
| Special radiation treatment CPT 77470 | $4,204.00 | $5,255.00 | $45.63 – $999.99 | 22 |
| Special teletx port plan CPT 77321 | $2,174.40 | $2,718.00 | $64.75 – $632.82 | 22 |
| Speech audiometry complete CPT 92556 | $136.00 | $170.00 | $18.75 – $102.69 | 21 |
| Speech recep thresh CPT 92555 | $99.20 | $124.00 | $8.13 – $102.69 | 21 |
| Spinal puncture lumbar diagnostic w/fluoroscopic or CT guidance CPT 62328 | $1,209.60 | $1,512.00 | $91.73 – $2,620.00 | 22 |
| Spirometry bronchodilation responsiveness pre/post bronchodilator administration CPT 94060 | $841.60 | $1,052.00 | $23.75 – $538.32 | 21 |
| Splint dorsal bloc wh med perf 3.2mm lf polyflex ii HCPCS L3906 | $147.20 | $184.00 | $312.50 – $824.67 | 16 |
| Splint finger frog med HCPCS L3927 | $79.20 | $99.00 | $28.13 – $65.49 | 16 |
| Split atogrft f/s/n/h/f/g/m/d gt 1st 100sqcm/</1 % CPT 15120 | not published | not published | $1,101.92 – $6,328.67 | 17 |
| Split blood or products CPT 86985 | $653.60 | $817.00 | $128.52 – $488.22 | 18 |
| St analysis behavior qualitative voice/resonance CPT 92524 | $400.80 | $501.00 | $50.00 – $181.09 | 20 |
| Staph a dna amp probe CPT 87640 | $145.60 | $182.00 | $35.09 – $159.31 | 25 |
| St cognitve performance testing healthcare professional each hour CPT 96125 | $270.40 | $338.00 | $50.00 – $168.65 | 21 |
| Stenger test pure tone CPT 92565 | $89.60 | $112.00 | $14.39 – $102.69 | 21 |
| Stent iliac/open or perc/uni/init 37221 CPT 37221 | $22,448.00 | $28,060.00 | $6,420.00 – $16,056.00 | 2 |
| St evaluate speech sound production CPT 92522 | $347.20 | $434.00 | $50.00 – $184.24 | 20 |
| St evaluate speech sound production comprehensive/expressive CPT 92523 | $400.80 | $501.00 | $50.00 – $378.46 | 20 |
| St evaluation motion fluoroscopic swallow function cine/video CPT 92611 | $430.40 | $538.00 | $52.90 – $149.84 | 21 |
| St evaluation swallow function CPT 92610 | $433.60 | $542.00 | $50.00 – $140.75 | 21 |
| Stress test pulmonary CPT 94618 | $455.20 | $569.00 | $33.90 – $222.83 | 21 |
| St treatment speech individual CPT 92507 | $400.80 | $501.00 | $27.13 – $127.10 | 21 |
| St treatment swallow dysfunction/oral CPT 92526 | $296.80 | $371.00 | $50.00 – $139.86 | 21 |
| Subtalar arthro w/deb CPT 29906 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Sugars single quant CPT 84378 | $48.00 | $60.00 | $11.53 – $52.35 | 25 |
| Sulfamethoxazole 400 mg-trimethoprim 80 mg/5 ml intravenous solution HCPCS J2865 | $90.00 | $112.50 | $0.05 – $33.60 | 10 |
| Surgical pathology level 1 gross examination only CPT 88300 | $104.00 | $130.00 | $6.85 – $85.11 | 25 |
| Surgical pathology level 2 gross & microscopic examination CPT 88302 | $104.00 | $130.00 | $14.11 – $141.92 | 25 |
| Surgical pathology level 3 gross & microscopic examination CPT 88304 | $208.80 | $261.00 | $20.66 – $184.46 | 25 |
| Surgical pathology level 4 gross & microscopic examination CPT 88305 | $218.40 | $273.00 | $19.89 – $311.94 | 25 |
| Surgical pathology level 5 gross & microscopic examination CPT 88307 | $1,124.00 | $1,405.00 | $56.88 – $1,256.26 | 25 |
| Surgical pathology level 6 gross & microscopic examination CPT 88309 | $1,920.00 | $2,400.00 | $84.50 – $2,457.87 | 25 |
| Susceptibility enzyme detection per enzyme CPT 87185 | $20.00 | $25.00 | $4.75 – $21.57 | 25 |
| Susceptibility mic per plate CPT 87186 | $36.00 | $45.00 | $8.65 – $39.27 | 25 |
| Suscept studies macrobroth dilution ea CPT 87188 | $27.20 | $34.00 | $6.64 – $30.15 | 25 |
| Syphilis test non-treponemal antibody quantitative rpr CPT 86593 | $18.40 | $23.00 | $4.40 – $28.67 | 25 |
| T3 (triiodothyronine) free CPT 84481 | $70.40 | $88.00 | $16.94 – $79.59 | 25 |
| T3 (triiodothyronine) total CPT 84480 | $59.20 | $74.00 | $10.00 – $64.38 | 25 |
| T4 (thyroxine) free CPT 84439 | $35.00 | $47.00 | $9.02 – $40.95 | 26 |
| T4 (thyroxine) total CPT 84436 | $28.00 | $35.00 | $6.87 – $32.30 | 25 |
| Tacrolimus 1 mg capsule, immediate-release HCPCS J7507 | $7.40 | $9.25 | $0.13 – $0.67 | 9 |
| Tacrolimus therapeutic drug level CPT 80197 | $50.00 | $72.00 | $13.73 – $62.33 | 25 |
| Tbo-filgrastim 300 mcg/0.5 ml subcutaneous syringe HCPCS J1447 | $899.40 | $1,124.25 | $0.30 – $388.50 | 25 |
| Tbs techl calculation only CPT 77091 | $398.40 | $498.00 | $26.95 – $497.84 | 18 |
| Tb test cell mediated immunity antigen response gamma interferon CPT 86480 | $257.60 | $322.00 | $61.98 – $403.43 | 25 |
| Tc-99m non-heu per study dose HCPCS Q9969 | $17.60 | $22.00 | $3.96 – $17.50 | 17 |
| T cells absolute cd4/cd8 including ratio CPT 86360 | $195.20 | $244.00 | $46.98 – $218.42 | 25 |
| T cells absolute cd 4 count CPT 86361 | $111.20 | $139.00 | $26.78 – $121.58 | 25 |
| T cells total count CPT 86359 | $157.60 | $197.00 | $37.73 – $245.56 | 25 |
| Telethx isodose plan cplx CPT 77307 | $2,690.40 | $3,363.00 | $250.44 – $741.03 | 22 |
| Terbutaline 1 mg/ml subcutaneous solution HCPCS J3105 | $21.00 | $26.25 | $2.85 – $24.72 | 10 |
| Test pathogen(s) for platelets reference HCPCS P9100 | $238.40 | $298.00 | $44.55 – $102.69 | 17 |
| Test stress cardiovascular tracing only CPT 93017 | $1,118.40 | $1,398.00 | $58.13 – $538.32 | 21 |
| Tetanus immune globulin inj HCPCS J1670 | $3,981.40 | $4,976.75 | $450.35 – $2,015.16 | 25 |
| Theophylline therapeutic drug level CPT 80198 | $59.20 | $74.00 | $13.75 – $64.20 | 25 |
| Therapy nutrition individual initial f2f w/patient each 15 minutes CPT 97802 | $32.80 | $41.00 | $7.38 – $53.10 | 17 |
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.