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 |
|---|---|---|---|---|
| Critical care each additional 30 minutes CPT 99292 | $567.20 | $709.00 | $93.00 – $252.96 | 6 |
| Cryofibrinogen qualitative - sendout CPT 82585 | $59.20 | $74.00 | $6.25 – $64.20 | 25 |
| Cryoprecipitate each unit HCPCS P9012 | $328.80 | $411.00 | $47.68 – $111.25 | 17 |
| Crystal identification light microscopy CPT 89060 | $30.40 | $38.00 | $7.33 – $45.49 | 25 |
| CT 3d report other modality w/workstation CPT 76377 | $691.20 | $864.00 | $68.47 – $68.47 | 1 |
| Cta abdomen without & /or w/contrast CPT 74175 | $532.50 | $2,763.00 | $175.85 – $1,012.89 | 24 |
| Cta abdominal aorta & (both sides) ileofemoral lower extremity w runoff without & w/contrast CPT 75635 | $397.50 | $2,763.00 | $175.85 – $1,156.85 | 24 |
| Cta lower extremity without & w/contrast (both sides) CPT 73706 | $528.50 | $2,763.00 | $175.85 – $1,006.60 | 24 |
| Cta neck without &/or w/contrast CPT 70498 | $538.00 | $2,763.00 | $175.85 – $1,006.60 | 24 |
| CT Angiogram of Abdomen and Pelvis CPT 74174 | $517.50 | $3,682.00 | $352.78 – $2,106.92 | 24 |
| CT Angiogram of the Chest (for blood clot) CPT 71275 | $531.50 | $2,649.00 | $175.85 – $1,040.30 | 24 |
| CT Angiogram of the Head CPT 70496 | $538.00 | $2,763.00 | $175.85 – $1,006.60 | 24 |
| CT angio hrt w/3d image CPT 75574 | $407.00 | $2,107.00 | $352.78 – $1,017.76 | 22 |
| CT angio pelvis CPT 72191 | $534.00 | $2,763.00 | $175.85 – $1,006.60 | 24 |
| Cta upper extremity w &/or without contrast left CPT 73206 | $535.50 | $2,763.00 | $175.85 – $1,006.60 | 24 |
| CT guidance for needle placement CPT 77012 | $1,810.40 | $2,263.00 | $132.81 – $539.85 | 8 |
| CT guidance for percutaneous drain w/catheter placement supervision & interpretation CPT 75989 | $1,862.40 | $2,328.00 | $21.88 – $78.02 | 8 |
| CT heart w/evaluation of calcium without contrast CPT 75571 | $85.50 | $135.00 | $41.78 – $497.84 | 23 |
| CT hrt w/3d image CPT 75572 | $445.50 | $2,107.00 | $295.45 – $803.62 | 22 |
| CT lower extremity w/contrast (both sides) CPT 73701 | $475.50 | $2,362.00 | $170.11 – $1,006.60 | 24 |
| CT lower extremity without contrast (both sides) CPT 73700 | $285.50 | $1,610.00 | $105.04 – $602.31 | 24 |
| CT lwr extremity w/o&w/dye CPT 73702 | $572.00 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| CT neck soft tissue w/contrast CPT 70491 | $461.50 | $2,362.00 | $171.88 – $1,006.60 | 24 |
| CT neck soft tissue without contrast CPT 70490 | $268.00 | $1,610.00 | $105.04 – $602.31 | 24 |
| CT neck soft tissue without & w/contrast CPT 70492 | $557.50 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| CT orbit/sella/fossa w/wo contrast CPT 70482 | $557.50 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| CT orbit/sella/ or posterior outer inner or middle ear w/contrast CPT 70481 | $461.50 | $2,362.00 | $175.85 – $1,006.60 | 24 |
| CT orbit/sella/ or posterior outer inner or middle ear without contrast CPT 70480 | $268.00 | $1,610.00 | $105.04 – $602.31 | 24 |
| CT scan for therapy guide CPT 77014 | $1,169.60 | $1,462.00 | $124.44 – $338.47 | 8 |
| CT Scan of Abdomen and Pelvis (with and without contrast) CPT 74178 | $525.00 | $3,188.00 | $318.38 – $2,106.92 | 24 |
| CT Scan of Abdomen and Pelvis (with contrast) CPT 74177 | $437.50 | $3,012.00 | $240.91 – $2,106.92 | 24 |
| CT Scan of Abdomen and Pelvis (without contrast) CPT 74176 | $242.50 | $2,322.00 | $126.34 – $1,342.45 | 24 |
| CT thoracic spine w/contrast CPT 72129 | $472.00 | $2,362.00 | $175.85 – $1,006.60 | 24 |
| CT thoracic spine without contrast CPT 72128 | $286.50 | $1,610.00 | $105.04 – $602.31 | 24 |
| CT thorax low dose for lung screening without contrast CPT 71271 | $266.00 | $1,206.00 | $91.72 – $602.31 | 24 |
| CT t-spine w /wo contrast CPT 72130 | $568.50 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| CT upper extremity w/contrast (both sides) CPT 73201 | $475.50 | $2,350.00 | $170.11 – $2,106.92 | 24 |
| CT upper extremity without contrast (both sides) CPT 73200 | $285.50 | $1,610.00 | $105.04 – $602.31 | 24 |
| CT uppr extremity w/o&w/dye CPT 73202 | $572.00 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| Culture aerobic additional method definitive id each CPT 87077 | $33.60 | $42.00 | $8.08 – $41.77 | 25 |
| Culture afb any source CPT 87116 | $44.80 | $56.00 | $9.38 – $70.35 | 25 |
| Culture anaerobic additional method definitive id each CPT 87076 | $33.60 | $42.00 | $8.08 – $41.77 | 25 |
| Culture anaerobic except blood CPT 87075 | $39.20 | $49.00 | $9.47 – $61.57 | 25 |
| Culture bact stool aero addl path ea CPT 87046 | $39.20 | $49.00 | $3.26 – $43.24 | 25 |
| Culture body fluid CPT 87070 | $36.00 | $45.00 | $8.62 – $39.13 | 25 |
| Culture fungi definitive id mold CPT 87107 | $43.20 | $54.00 | $10.32 – $67.19 | 25 |
| Culture fungi definitive id yeast CPT 87106 | $43.20 | $54.00 | $10.32 – $58.68 | 25 |
| Culture fungi other (except blood) CPT 87102 | $35.20 | $44.00 | $8.41 – $54.66 | 25 |
| Culture fungi skin/hair/nail CPT 87101 | $32.80 | $41.00 | $7.71 – $50.20 | 25 |
| Culture mycobacteria definitive id each isolate CPT 87118 | $60.80 | $76.00 | $14.61 – $66.33 | 25 |
| Culture mycoplasma any source CPT 87109 | $64.00 | $80.00 | $15.39 – $74.16 | 25 |
| Culture quantitative aerobic other source CPT 87071 | $40.80 | $51.00 | $6.53 – $61.39 | 25 |
| Culture screening strep group a CPT 87081 | $27.20 | $34.00 | $6.50 – $41.77 | 25 |
| Culture typing immunologic CPT 87147 | $21.60 | $27.00 | $3.75 – $33.70 | 25 |
| Culture typing nucleic acid probe amplified per culture/isolate 6 or more targets CPT 87154 | $872.24 | $1,090.30 | $32.36 – $989.99 | 21 |
| Culture typing nucleic acid probe amplified per culture/isolate each organism CPT 87150 | $175.20 | $219.00 | $35.09 – $159.31 | 25 |
| Cyanocobalamin (vit b-12) 1,000 mcg/ml injection solution HCPCS J3420 | $21.60 | $27.00 | $0.69 – $3.36 | 10 |
| Cyclic citrullinated peptide antibody CPT 86200 | $54.40 | $68.00 | $12.95 – $84.31 | 25 |
| Cyclophosphamide 25 mg capsule HCPCS J8530 | $17.60 | $22.00 | $0.83 – $6.34 | 10 |
| Cyclosporine 2 hour CPT 80158 | $75.20 | $94.00 | $18.05 – $81.95 | 25 |
| Cyclosporine modified 25 mg capsule HCPCS J7515 | $10.60 | $13.25 | $0.61 – $2.68 | 10 |
| Cyclosporine oral 100 mg HCPCS J7502 | $11.60 | $14.50 | $1.55 – $7.07 | 10 |
| Cyp2c19 gene com variants CPT 81225 | $1,059.20 | $1,324.00 | $238.32 – $1,322.77 | 19 |
| Cystatin c CPT 82610 | $77.60 | $97.00 | $18.52 – $88.50 | 25 |
| Cystine urine quantitative CPT 82131 | $96.00 | $120.00 | $22.98 – $104.33 | 25 |
| Cystogram >= 3 views supervision & interpretation CPT 74430 | $531.20 | $664.00 | $45.63 – $2,106.92 | 23 |
| Cystoscopy and treatment CPT 52260 | not published | not published | $1,101.92 – $6,120.66 | 3 |
| Cystoscopy and treatment CPT 52276 | not published | not published | $1,101.92 – $7,441.00 | 3 |
| Cystoscopy and treatment CPT 52315 | not published | not published | $1,101.92 – $7,441.00 | 3 |
| Cystouretero & or pyeloscope CPT 52351 | not published | not published | $1,101.92 – $10,305.03 | 3 |
| Cystouretero w/biopsy CPT 52354 | not published | not published | $1,101.92 – $15,189.14 | 3 |
| Cystourethroscop/calib/dilat stric 52281 CPT 52281 | not published | not published | $1,101.92 – $6,120.66 | 3 |
| Cysto w/up stricture tx CPT 52342 | not published | not published | $1,101.92 – $10,305.03 | 3 |
| Cysto w/ureter stricture tx CPT 52341 | not published | not published | $1,101.92 – $10,305.03 | 3 |
| Cytomegalovirus (cmv) antibody igg CPT 86644 | $60.00 | $75.00 | $14.39 – $83.03 | 25 |
| Cytomegalovirus (cmv) antibody igm CPT 86645 | $69.60 | $87.00 | $16.85 – $85.07 | 25 |
| Cytopathology cellular enhancement technique non-gyn CPT 88112 | $211.20 | $264.00 | $52.78 – $313.07 | 25 |
| Cytopathology cervical/vaginal thin layer auto screen/manual rescreen/review CPT 88175 | $112.00 | $140.00 | $21.69 – $120.81 | 25 |
| Cytopathology cervical/vaginal thin layer manual screening CPT 88142 | $84.00 | $105.00 | $20.00 – $91.98 | 24 |
| Cytopathology concentration technique smears & interpretation CPT 88108 | $143.20 | $179.00 | $20.00 – $287.25 | 25 |
| Cytopathology fluids/washings/brushings smears with interpretation CPT 88104 | $171.20 | $214.00 | $26.11 – $301.32 | 25 |
| Cytopathology fna adequacy evaluation first episode each site CPT 88172 | $130.40 | $163.00 | $29.34 – $488.22 | 20 |
| Cytopathology fna adequacy evaluation first episode each site interp/rpt CPT 88173 | $211.20 | $264.00 | $23.14 – $704.52 | 20 |
| Cytopath smear other source CPT 88160 | $104.80 | $131.00 | $15.63 – $326.56 | 25 |
| Cytp urine 3-5 probes cmptr CPT 88121 | $272.00 | $340.00 | $23.94 – $1,807.28 | 25 |
| Daptomycin 500 mg/10 ml intravenous solution HCPCS J0878 | $185.20 | $231.50 | $0.03 – $52.50 | 10 |
| Darbepoetin alfa 100 mcg/0.5 ml in polysorbate injection syringe HCPCS J0881 | $8,881.40 | $11,101.75 | $3.17 – $397.60 | 25 |
| Deamidated gliadin antibody iga CPT 86258 | $60.00 | $75.00 | $12.05 – $54.71 | 20 |
| Debridement (>20 cm) charge pt CPT 97598 | $576.00 | $720.00 | $14.45 – $39.30 | 7 |
| Debridement bone <= 20 sq cm CPT 11044 | $2,850.40 | $3,563.00 | $41.25 – $4,841.06 | 9 |
| Debridement/bone/20 sq cm or less 11046 CPT 11046 | $1,077.60 | $1,347.00 | $38.04 – $1,209.00 | 2 |
| Debridement subcutaneous tissue <= 20 sq cm CPT 11042 | $1,077.60 | $1,347.00 | $41.25 – $1,131.20 | 22 |
| Debride nail6 or more 11721 CPT 11721 | $155.20 | $194.00 | $25.00 – $1,131.20 | 22 |
| Debride skin bone at fx site CPT 11012 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Debride/subq tissue/ea add 20sq cm 11045 CPT 11045 | $1,077.60 | $1,347.00 | $18.06 – $1,131.20 | 2 |
| Debr musc/fascia 20sq cm/< 11043 CPT 11043 | $1,077.60 | $1,347.00 | $41.25 – $1,131.20 | 22 |
| Decalcification CPT 88311 | $91.20 | $114.00 | $20.90 – $89.94 | 11 |
| Declotting thrombolytic agent implanted vas access device 36 CPT 36593 | $1,002.40 | $1,253.00 | $31.33 – $1,131.20 | 22 |
| Deferoxamine 500 mg solution for injection HCPCS J0895 | $203.00 | $253.75 | $6.84 – $30.13 | 10 |
| Delivery of placenta 59414 CPT 59414 | $3,380.00 | $4,225.00 | $106.78 – $6,066.00 | 8 |
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.