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 |
|---|---|---|---|---|
| Therapy nutrition individual reassessment/intervention f2f w/patient each 15 minutes CPT 97803 | $32.80 | $41.00 | $7.38 – $44.89 | 17 |
| Thiamine hcl (vitamin b1) 100 mg/ml injection solution HCPCS J3411 | $129.80 | $162.25 | $1.97 – $12.32 | 10 |
| Thoracentesis pleural space needle/catheter aspiration with imaging guidance (both sides) CPT 32555 | $1,308.00 | $1,635.00 | $110.88 – $2,402.40 | 22 |
| Thrombectomy/inf pq dialysis circuit CPT 36904 | $10,528.00 | $13,160.00 | $350.08 – $16,056.00 | 8 |
| Thrombectomy/inf pq dialysis circuit w/pta CPT 36905 | $21,760.80 | $27,201.00 | $439.41 – $28,500.00 | 8 |
| Thrombectomy/inf pq dialysis circuit w/stent plcmnt CPT 36906 | $33,167.20 | $41,459.00 | $512.80 – $28,500.00 | 8 |
| Thrombin time CPT 85670 | $40.80 | $51.00 | $5.77 – $33.33 | 25 |
| Thromboplastin time partial (ptt) substitution fractions each CPT 85732 | $30.40 | $38.00 | $6.47 – $41.77 | 25 |
| Thyroglobulin antibody CPT 86800 | $66.40 | $83.00 | $15.91 – $103.52 | 25 |
| Thyroid (TSH) Test CPT 84443 | $40.00 | $119.00 | $16.80 – $78.91 | 26 |
| Thyroid Ultrasound CPT 76536 | $1,031.20 | $1,289.00 | $76.18 – $602.31 | 24 |
| Thyroxine binding globulin (tbg) CPT 84442 | $61.60 | $77.00 | $12.50 – $67.10 | 25 |
| Tilt table study CPT 93660 | $1,641.60 | $2,052.00 | $524.14 – $917.25 | 15 |
| Tissue culture skin/biopsy CPT 88233 | $591.20 | $739.00 | $97.75 – $642.60 | 25 |
| Tissue exam koh skin/hair/nails CPT 87220 | $17.60 | $22.00 | $4.27 – $22.51 | 25 |
| Tissue transglutaminase iga CPT 86364 | $48.00 | $60.00 | $10.80 – $52.35 | 20 |
| Tobramycin in ns IV syringe 4 mg/ml (neo/ped) - cnr HCPCS J3260 | $618.80 | $773.50 | $1.80 – $7.94 | 10 |
| Tobramycin peak therapeutic drug level CPT 80200 | $67.20 | $84.00 | $16.13 – $73.23 | 25 |
| Tomosynthesis breast screen bilateral CPT 77063 | $91.20 | $114.00 | $21.59 – $149.70 | 24 |
| Tone decay hearing test CPT 92563 | $93.60 | $117.00 | $17.76 – $67.85 | 21 |
| Toxoplasma antibody igg CPT 86777 | $60.00 | $75.00 | $14.39 – $93.71 | 25 |
| Toxoplasma antibody igm CPT 86778 | $60.00 | $75.00 | $14.41 – $67.66 | 25 |
| Tpmt gene com vrnts CPT 81335 | $360.80 | $451.00 | $17.34 – $793.64 | 18 |
| Tracheobrnchsc thru est trachs incisn CPT 31615 | $1,532.00 | $1,915.00 | $143.49 – $2,448.60 | 22 |
| Training self management diabetes individual outpatient department per 30 minutes HCPCS G0108 | $56.00 | $70.00 | $26.76 – $89.78 | 21 |
| Transcath biopsy CPT 37200 | $9,697.60 | $12,122.00 | $142.50 – $7,441.00 | 8 |
| Transcatheter bx s&i CPT 75970 | $1,067.20 | $1,334.00 | $21.88 – $475.43 | 8 |
| Transferrin CPT 84466 | $50.00 | $67.00 | $12.76 – $57.93 | 26 |
| Transfusion blood/blood component(s) CPT 36430 | $1,714.40 | $2,143.00 | $34.80 – $2,402.40 | 22 |
| Treat clavicle dislocation 23545 CPT 23545 | not published | not published | $236.96 – $2,620.00 | 17 |
| Treat finger fracture each CPT 26742 | $2,829.60 | $3,537.00 | $91.88 – $1,131.20 | 8 |
| Treat fracture of radius CPT 25505 | $864.00 | $1,080.00 | $181.25 – $2,448.60 | 8 |
| Treat kneecap fracture CPT 27524 | not published | not published | $1,101.92 – $21,344.46 | 3 |
| Treat knee fracture 27530 CPT 27530 | $1,526.40 | $1,908.00 | $160.63 – $1,131.20 | 22 |
| Treatment inhalation continuous aerosol medication acute airway obstruction 1st hour CPT 94644 | $549.60 | $687.00 | $32.13 – $222.83 | 21 |
| Treatment inhalation continuous aerosol medication acute airway obstruction each additional hour CPT 94645 | $359.20 | $449.00 | $12.25 – $33.32 | 7 |
| Treatment inhalation pressurized/nonpressurized acute airway obstruction CPT 94640 | $309.60 | $387.00 | $69.66 – $351.59 | 16 |
| Treatment of ankle fracture CPT 27823 | not published | not published | $1,101.92 – $21,344.46 | 3 |
| Treatment of ankle fracture 27786 CPT 27786 | $685.60 | $857.00 | $148.13 – $1,131.20 | 22 |
| Treatment of fibula fracture 27780 CPT 27780 | $690.40 | $863.00 | $144.38 – $1,131.20 | 18 |
| Treatment of toe fracture 28510 CPT 28510 | $1,374.40 | $1,718.00 | $61.25 – $1,131.20 | 18 |
| Treat radius fracture CPT 24665 | not published | not published | $1,101.92 – $21,344.46 | 3 |
| Treat thigh fracture CPT 27246 | $451.20 | $564.00 | $140.00 – $2,448.60 | 22 |
| Treponema pallidum antibody CPT 86780 | $65.60 | $82.00 | $13.24 – $71.25 | 25 |
| Trg gene rearrangement anal CPT 81342 | $838.40 | $1,048.00 | $60.55 – $914.81 | 20 |
| Triamcinolone acetonide 40 mg/ml suspension for injection HCPCS J3301 | $145.00 | $181.25 | $0.92 – $12.18 | 10 |
| Triglycerides CPT 84478 | $24.00 | $30.00 | $5.74 – $26.06 | 25 |
| Trimethobenzamide hcl inj HCPCS J3250 | $650.60 | $813.25 | $43.67 – $192.30 | 10 |
| Trim nondyst nails CPT 11719 | $100.00 | $125.00 | $22.50 – $1,131.20 | 18 |
| Trnscath plc vas stent w/s&i ini vein CPT 37238 | $22,448.00 | $28,060.00 | $6,420.00 – $28,500.00 | 2 |
| Trnscath tx thromblytc artery non-intracrn ini day CPT 37211 | $2,880.00 | $3,600.00 | $404.81 – $4,396.00 | 8 |
| Trnscath tx thromblytc cath rmv sbsq day CPT 37214 | $3,432.00 | $4,290.00 | $7,441.00 – $7,441.00 | 1 |
| Troponin quantitative CPT 84484 | $62.40 | $78.00 | $12.34 – $51.50 | 24 |
| Tx closed hip disl traumatic without anes CPT 27250 | $1,441.60 | $1,802.00 | $236.96 – $1,131.20 | 22 |
| Tx closed tib shaft fx without manip CPT 27750 | $759.20 | $949.00 | $178.13 – $1,131.20 | 22 |
| Tx open art fx mcp/iphlngl jnt incl int fixtn ea CPT 26746 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Tx tarsal bone fx without manip 28450 CPT 28450 | $723.20 | $904.00 | $142.50 – $1,131.20 | 22 |
| Tympanometry & reflex thresh CPT 92550 | $136.00 | $170.00 | $20.31 – $270.46 | 21 |
| Ultrasound abdomen aorta screening study aaa CPT 76706 | $752.00 | $940.00 | $62.64 – $602.31 | 24 |
| Ultrasound breast complete CPT 76641 | $540.80 | $676.00 | $66.79 – $602.31 | 24 |
| Ultrasound breast unilateral limited (both sides) CPT 76642 | $492.00 | $615.00 | $51.17 – $497.84 | 24 |
| Ultrasound chest CPT 76604 | $631.20 | $789.00 | $54.11 – $602.31 | 24 |
| Ultrasound elastography parenchyma CPT 76981 | $249.60 | $312.00 | $56.16 – $602.31 | 19 |
| Ultrasound encephalogram CPT 76506 | $588.80 | $736.00 | $58.05 – $602.31 | 24 |
| Ultrasound exam k transpl w/doppler CPT 76776 | $544.00 | $680.00 | $98.70 – $602.31 | 24 |
| Ultrasound fetal biophysical profile without non-stress testing CPT 76819 | $525.60 | $657.00 | $51.61 – $602.31 | 23 |
| Ultrasound guidance for vascular access CPT 76937 | $504.00 | $630.00 | $19.91 – $86.80 | 8 |
| Ultrasound guided needle placement supervision & interpretation CPT 76942 | $941.60 | $1,177.00 | $90.00 – $244.80 | 8 |
| Ultrasound hips infant dynamic CPT 76885 | $636.80 | $796.00 | $58.05 – $497.84 | 24 |
| Ultrasound joint/nonvascular extremity limited left CPT 76882 | $468.00 | $585.00 | $9.81 – $602.31 | 24 |
| Ultrasound pregnant uterus < 14 weeks each additional gestation CPT 76802 | $336.80 | $421.00 | $31.03 – $191.00 | 9 |
| Ultrasound pregnant uterus follow up per fetus CPT 76816 | $836.80 | $1,046.00 | $58.00 – $602.31 | 24 |
| Ultrasound pregnant uterus limited >= 1 fetuses CPT 76815 | $533.60 | $667.00 | $54.16 – $602.31 | 24 |
| Ultrasound pregnant uterus transvaginal CPT 76817 | $533.60 | $667.00 | $58.05 – $602.31 | 24 |
| Ultrasound retroperitoneal limited CPT 76775 | $1,015.20 | $1,269.00 | $75.18 – $602.31 | 24 |
| Ultrasound scrotum and contents CPT 76870 | $729.60 | $912.00 | $80.30 – $602.31 | 24 |
| Ultrasound spinal canal and contents CPT 76800 | $320.80 | $401.00 | $63.50 – $602.31 | 24 |
| Ultrasound transvaginal non obstetric CPT 76830 | $708.80 | $886.00 | $58.13 – $602.31 | 23 |
| Unlistd noninvas vasc dx std CPT 93998 | $528.80 | $661.00 | $18.37 – $98.82 | 17 |
| Unlisted fluoroscopic px CPT 76496 | $400.00 | $500.00 | $66.04 – $497.84 | 19 |
| Unlisted laparoscopic procedure 49659 CPT 49659 | not published | not published | $1,101.92 – $18,643.49 | 3 |
| Unlisted mr procedure CPT 76498 | $400.00 | $500.00 | $66.04 – $497.84 | 19 |
| Unsched dialysis esrd pt hos HCPCS G0257 | $872.00 | $1,090.00 | $49.14 – $1,209.60 | 16 |
| Upgrade pm system CPT 33214 | $54,780.00 | $68,475.00 | $6,420.00 – $28,500.00 | 3 |
| Upper Back (Thoracic Spine) MRI (with and without contrast) CPT 72157 | $700.50 | $2,646.00 | $352.78 – $2,106.92 | 24 |
| Upper Back (Thoracic Spine) MRI (with contrast) CPT 72147 | $633.50 | $2,350.00 | $352.78 – $2,106.92 | 24 |
| Upper Back (Thoracic Spine) MRI (without contrast) CPT 72146 | $454.00 | $2,225.00 | $238.78 – $1,342.45 | 24 |
| Urea nitrogen CPT 84520 | $16.80 | $21.00 | $3.95 – $18.50 | 25 |
| Urea nitrogen 24 hour urine CPT 84540 | $23.20 | $29.00 | $4.17 – $25.24 | 21 |
| Urethrcystgrphy rtrgrde s&i CPT 74450 | $672.00 | $840.00 | $46.88 – $1,342.45 | 23 |
| Urethrocystography void s&i CPT 74455 | $600.00 | $750.00 | $53.13 – $1,342.45 | 23 |
| Uric acid blood CPT 84550 | $15.00 | $24.00 | $4.52 – $21.22 | 25 |
| Uric acid urine CPT 84560 | $20.80 | $26.00 | $5.05 – $23.06 | 25 |
| Urinalysis microscopic only CPT 81015 | $12.80 | $16.00 | $3.05 – $13.85 | 25 |
| Urinalysis (with microscopy) CPT 81001 | $10.00 | $21.00 | $3.17 – $14.39 | 26 |
| Urinalysis (without microscopy) CPT 81003 | $10.00 | $11.00 | $2.25 – $10.54 | 25 |
| Urine Culture Test CPT 87086 | $25.00 | $42.00 | $8.07 – $52.56 | 26 |
| Urine pregnancy test CPT 81025 | $36.00 | $45.00 | $5.00 – $39.09 | 25 |
| Urography, antegrade CPT 74425 | $531.20 | $664.00 | $46.88 – $2,106.92 | 23 |
| Vaccine hepatitis b (hepb) adult 3 dose im CPT 90746 | $834.80 | $1,043.50 | $12.50 – $269.75 | 11 |
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.