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 |
|---|---|---|---|---|
| Whfo w/joint(s) custom fab HCPCS L3806 | $587.20 | $734.00 | $338.80 – $850.80 | 16 |
| Wound therapy negative pressure per session <= 50 sq cm CPT 97607 | $296.80 | $371.00 | $50.00 – $690.66 | 20 |
| Wound therapy negative pressure per session > 50 sq cm CPT 97608 | $522.40 | $653.00 | $50.00 – $690.66 | 20 |
| Wound therapy negative pressure per session <= 50 sq cm dme CPT 97605 | $315.20 | $394.00 | $50.00 – $343.49 | 20 |
| Wound therapy negative pressure per session > 50 sq cm dme CPT 97606 | $556.00 | $695.00 | $50.00 – $690.66 | 20 |
| Wrist X-ray CPT 73110 | $368.80 | $461.00 | $22.80 – $497.84 | 24 |
| Xfer tis f/c/c/m/n/a/g/h/f 10sq cm/< CPT 14040 | not published | not published | $1,101.92 – $4,396.00 | 17 |
| X-ray abdomen 1 view CPT 74018 | $280.00 | $350.00 | $17.22 – $497.84 | 24 |
| X-ray abdomen 2 views CPT 74019 | $320.80 | $401.00 | $20.59 – $602.31 | 24 |
| X-ray abdomen >=3 views CPT 74021 | $349.60 | $437.00 | $23.96 – $602.31 | 24 |
| X-ray abdomen complete acute series including spine erect and/or decubitus single view chest CPT 74022 | $1,003.20 | $1,254.00 | $29.64 – $602.31 | 24 |
| X-ray acromioclavicular joints without or w/weighted distraction bilateral CPT 73050 | $224.00 | $280.00 | $23.24 – $497.84 | 24 |
| X-ray ankle 2 views (both sides) CPT 73600 | $301.60 | $377.00 | $17.13 – $497.84 | 24 |
| X-ray arthrogram shoulder supervision & interpretation (both sides) CPT 73040 | $1,144.00 | $1,430.00 | $34.38 – $2,106.92 | 24 |
| X-ray bone age studies CPT 77072 | $246.40 | $308.00 | $12.79 – $602.31 | 23 |
| X-ray bone length studies CPT 77073 | $560.00 | $700.00 | $22.30 – $602.31 | 23 |
| X-ray bone survey complete CPT 77075 | $693.60 | $867.00 | $66.84 – $602.31 | 23 |
| X-ray bone survey infant CPT 77076 | $501.60 | $627.00 | $53.99 – $602.31 | 23 |
| X-ray cervical spine 2-3 views CPT 72040 | $484.00 | $605.00 | $23.58 – $497.84 | 24 |
| X-ray cervical spine 4-5 views CPT 72050 | $640.00 | $800.00 | $33.70 – $602.31 | 24 |
| X-ray cervical spine >= 6 views CPT 72052 | $807.20 | $1,009.00 | $43.04 – $602.31 | 24 |
| X-ray clavicle complete (both sides) CPT 73000 | $292.00 | $365.00 | $17.46 – $497.84 | 24 |
| X-ray colon abdominal radiograph(s) & delayed images single contrast study CPT 74270 | $954.40 | $1,193.00 | $46.88 – $1,006.60 | 23 |
| X-ray colon abdominal radiograph(s) & delayed images with glucagon double contrast study CPT 74280 | $1,141.60 | $1,427.00 | $81.25 – $1,006.60 | 23 |
| X-ray elbow 2 views (both sides) CPT 73070 | $270.40 | $338.00 | $17.46 – $497.84 | 24 |
| X-ray elbow >= 3 views (both sides) CPT 73080 | $398.40 | $498.00 | $23.58 – $497.84 | 24 |
| X-ray esophogram chest radiograph(s) & delayed images single contrast study CPT 74220 | $479.20 | $599.00 | $46.88 – $1,006.60 | 23 |
| X-ray exam entire spi 4/5 vw CPT 72083 | $740.80 | $926.00 | $46.59 – $602.31 | 24 |
| X-ray exam entire spi 6/> vw CPT 72084 | $820.00 | $1,025.00 | $56.23 – $602.31 | 24 |
| X-ray exam of arm infant CPT 73092 | $312.00 | $390.00 | $18.13 – $602.31 | 24 |
| X-ray exam of eye sockets CPT 70200 | $272.00 | $340.00 | $27.64 – $602.31 | 24 |
| X-ray exam of femur 1 CPT 73551 | $351.20 | $439.00 | $17.98 – $497.84 | 24 |
| X-ray exam of sinuses CPT 70210 | $261.60 | $327.00 | $19.57 – $497.84 | 24 |
| X-ray exam si joints CPT 72200 | $312.00 | $390.00 | $18.46 – $602.31 | 24 |
| X-ray exam thorac spine4/>vw CPT 72074 | $501.60 | $627.00 | $31.36 – $602.31 | 24 |
| X-ray eye detection foreign body (both sides) CPT 70030 | $241.60 | $302.00 | $17.79 – $497.84 | 24 |
| X-ray facial bones complete > 3 views CPT 70150 | $501.60 | $627.00 | $27.30 – $602.31 | 24 |
| X-ray femur >=2 views (both sides) CPT 73552 | $398.40 | $498.00 | $21.31 – $497.84 | 24 |
| X-ray finger(s) >= 2 views (both sides) CPT 73140 | $280.80 | $351.00 | $17.50 – $497.84 | 24 |
| X-ray foot 2 views (both sides) CPT 73620 | $231.20 | $289.00 | $16.46 – $497.84 | 24 |
| X-ray forearm 2 views (both sides) CPT 73090 | $284.80 | $356.00 | $17.46 – $497.84 | 24 |
| X-ray hand 2 views (both sides) CPT 73120 | $280.00 | $350.00 | $17.13 – $602.31 | 24 |
| X-ray heel/calcaneus > 2 views (both sides) CPT 73650 | $261.60 | $327.00 | $16.79 – $497.84 | 24 |
| X-ray hip uni w/wo pelvis min 4 views CPT 73503 | $477.60 | $597.00 | $34.61 – $602.31 | 24 |
| X-ray hip with pelvis when performed bilateral 2 views CPT 73521 | $501.60 | $627.00 | $25.97 – $602.31 | 24 |
| X-ray hip with pelvis when performed bilateral 3-4 views CPT 73522 | $501.60 | $627.00 | $31.29 – $602.31 | 24 |
| X-ray hip with pelvis when performed bilateral >= 5 views CPT 73523 | $742.40 | $928.00 | $37.61 – $602.31 | 24 |
| X-ray hip with pelvis when performed unilateral 1 view left CPT 73501 | $398.40 | $498.00 | $18.65 – $497.84 | 24 |
| X-ray humerus >= 2 views left CPT 73060 | $266.40 | $333.00 | $18.91 – $497.84 | 24 |
| X-ray knee 1-2 views (both sides) CPT 73560 | $262.40 | $328.00 | $17.79 – $497.84 | 24 |
| X-ray knee 3 views (both sides) CPT 73562 | $483.20 | $604.00 | $22.58 – $497.84 | 24 |
| X-ray knee ap standing bilateral CPT 73565 | $261.60 | $327.00 | $19.13 – $497.84 | 24 |
| X-ray lower extremities infant > 2 views (both sides) CPT 73592 | $300.00 | $375.00 | $18.13 – $497.84 | 24 |
| X-ray l/s-spine bend vw only 2-3 vw CPT 72120 | $280.00 | $350.00 | $34.37 – $602.31 | 24 |
| X-ray lumbosacral spine >= 4 views CPT 72110 | $526.40 | $658.00 | $35.37 – $602.31 | 24 |
| X-ray lumbosacral spine complete including bending views >= 6 views CPT 72114 | $659.20 | $824.00 | $43.75 – $602.31 | 24 |
| X-ray mandible complete > 4 views CPT 70110 | $312.00 | $390.00 | $24.58 – $602.31 | 24 |
| X-ray mandible ltd <4 views CPT 70100 | $224.00 | $280.00 | $19.46 – $497.84 | 24 |
| X-ray nasal bones complete > 3 views CPT 70160 | $358.40 | $448.00 | $21.13 – $497.84 | 24 |
| X-ray neck soft tissue CPT 70360 | $280.00 | $350.00 | $16.79 – $497.84 | 24 |
| X-ray nose to rectum for foreign body child CPT 76010 | $261.60 | $327.00 | $17.13 – $497.84 | 23 |
| X-ray pelvis 1-2 views CPT 72170 | $316.00 | $395.00 | $15.79 – $602.31 | 24 |
| X-ray pelvis complete > 3 views CPT 72190 | $480.00 | $600.00 | $26.25 – $602.31 | 24 |
| X-ray retrograde pyelogram with or without kidney ureter bladder w/supervision & interpretation CPT 74420 | $824.80 | $1,031.00 | $46.88 – $2,106.92 | 23 |
| X-ray ribs 2 views left CPT 71100 | $239.20 | $299.00 | $19.91 – $497.84 | 24 |
| X-ray ribs 3 views bilateral CPT 71110 | $501.60 | $627.00 | $25.30 – $602.31 | 24 |
| X-ray ribs w/posterior anterior chest 3 views left CPT 71101 | $417.60 | $522.00 | $23.91 – $602.31 | 24 |
| X-ray ribs w/posterior anterior chest > 4 views bilateral CPT 71111 | $501.60 | $627.00 | $33.37 – $602.31 | 24 |
| X-ray sacroiliac joints >= 3 views CPT 72202 | $432.00 | $540.00 | $23.24 – $602.31 | 24 |
| X-ray sacrum/coccyx >= 2 views CPT 72220 | $431.20 | $539.00 | $19.24 – $497.84 | 24 |
| X-ray scapula complete (both sides) CPT 73010 | $336.00 | $420.00 | $17.79 – $602.31 | 24 |
| X-ray shoulder 1 view (both sides) CPT 73020 | $264.00 | $330.00 | $14.46 – $497.84 | 24 |
| X-ray sinuses paranasal complete > 3 views CPT 70220 | $501.60 | $627.00 | $24.64 – $497.84 | 24 |
| X-ray sinus tract/fistula/abscess CPT 76080 | $1,128.00 | $1,410.00 | $33.37 – $3,022.37 | 23 |
| X-ray skull < 4 views CPT 70250 | $418.40 | $523.00 | $22.24 – $602.31 | 24 |
| X-ray skull > 4 views complete CPT 70260 | $654.40 | $818.00 | $28.69 – $602.31 | 24 |
| X-ray small bowel multi serial images abdominal radiographs(s)&delayed images single contrast study CPT 74250 | $694.40 | $868.00 | $46.88 – $1,006.60 | 23 |
| X-ray small intestine follow-through study CPT 74248 | $1,380.80 | $1,726.00 | $44.98 – $217.80 | 8 |
| X-ray spine single view CPT 72020 | $269.60 | $337.00 | $14.46 – $497.84 | 24 |
| X-ray sternoclavicular joint(s) > 3 views CPT 71130 | $469.60 | $587.00 | $23.75 – $497.84 | 24 |
| X-ray sternum > 2 views CPT 71120 | $360.00 | $450.00 | $20.91 – $497.84 | 24 |
| X-ray surgical specimen CPT 76098 | $987.20 | $1,234.00 | $10.79 – $3,022.37 | 23 |
| X-ray swallowing function w/ciner/videoradiography neck radiographs(s)&delayed images contrast study CPT 74230 | $590.40 | $738.00 | $57.11 – $1,006.60 | 23 |
| X-ray temporomandibular joint open/closed mouth bilateral CPT 70330 | $580.80 | $726.00 | $31.97 – $497.84 | 24 |
| X-ray thoracic spine 2 views CPT 72070 | $504.00 | $630.00 | $20.91 – $602.31 | 24 |
| X-ray thoracic spine 3 views CPT 72072 | $605.60 | $757.00 | $25.30 – $602.31 | 24 |
| X-ray thoracolumbar spine >=2 views CPT 72080 | $519.20 | $649.00 | $22.24 – $497.84 | 24 |
| X-ray thoracolumbar spine including skull cervical & sacral spine 1 view CPT 72081 | $372.80 | $466.00 | $23.64 – $497.84 | 24 |
| X-ray thoracolumbar spine including skull cervical & sacral spine 2-3 views CPT 72082 | $501.60 | $627.00 | $42.93 – $602.31 | 24 |
| X-ray tibia/fibula 2 views (both sides) CPT 73590 | $429.60 | $537.00 | $16.79 – $497.84 | 24 |
| X-ray toe(s) > 2 views (both sides) CPT 73660 | $280.00 | $350.00 | $17.50 – $497.84 | 24 |
| X-ray upper gastrointestinal tract scout abdominal radiographs delayed images double contrast CPT 74246 | $811.20 | $1,014.00 | $80.63 – $1,006.60 | 23 |
| X-ray upper gastrointestinal tract scout abdominal radiographs delayed images single contrast study CPT 74240 | $811.20 | $1,014.00 | $66.17 – $1,006.60 | 23 |
| X-ray wrist 2 views (both sides) CPT 73100 | $301.60 | $377.00 | $18.13 – $497.84 | 24 |
| Zidovudine in d5w IV syringe 4 mg/ml (neo/peds) - cnr HCPCS J3485 | $350.20 | $437.75 | $1.64 – $105.70 | 11 |
| Ziprasidone 20 mg/ml (final concentration) intramuscular solution HCPCS J3486 | $146.60 | $183.25 | $6.52 – $41.50 | 9 |
| Zoledronic acid 4 mg/5 ml intravenous solution HCPCS J3489 | $295.40 | $369.25 | $5.49 – $133.28 | 10 |
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.