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 |
|---|---|---|---|---|
| Demonstration/evaluation utilization aersol generator/nebulizer/metered dose inhaler/ippb device CPT 94664 | $295.20 | $369.00 | $14.78 – $351.59 | 21 |
| Dentoalveolar/drain abs/cyst/hema 41800 CPT 41800 | $679.20 | $849.00 | $29.38 – $1,131.20 | 22 |
| Design mlc device for imrt CPT 77338 | $4,412.00 | $5,515.00 | $361.61 – $992.70 | 17 |
| Desmopressin 4 mcg/ml injection solution HCPCS J2597 | $495.00 | $618.75 | $3.82 – $62.86 | 24 |
| Destruction by neurolytic agent w/imaging guidance lumbar/sacral additional (both sides) CPT 64636 | not published | not published | $1,101.92 – $5,834.62 | 3 |
| Devel tst phys/qhp 1st hr CPT 96112 | $276.00 | $345.00 | $128.18 – $348.64 | 21 |
| Device intraute mirena HCPCS J7298 | $7,201.60 | $9,002.00 | $850.24 – $4,664.19 | 10 |
| Dexa bone density study >=1 sites appendicular skeleton (peripheral) CPT 77081 | $323.20 | $404.00 | $18.30 – $497.84 | 24 |
| Dexamethasone 4 mg tablet HCPCS J8540 | $8.80 | $11.00 | $0.02 – $1.02 | 10 |
| Dexamethasone in ns IV syringe 0.1 mg/ml (neonate) - cnr HCPCS J1100 | $24.60 | $30.75 | $0.10 – $1.54 | 10 |
| Dextrose 5 % and 0.9 % sodium chloride intravenous solution HCPCS J7042 | $49.00 | $61.25 | $1.07 – $4.73 | 9 |
| Dextrose 5 % in water (d5w) intravenous solution (non-pvc) HCPCS J7060 | $36.00 | $45.00 | $1.37 – $6.37 | 9 |
| Dhea-s (dehydroepiand sulfate) CPT 82627 | $92.00 | $115.00 | $22.23 – $100.92 | 25 |
| Diabetes (HbA1c) Test CPT 83036 | $25.00 | $75.00 | $8.75 – $44.08 | 26 |
| Diab manage trn ind/group HCPCS G0109 | $34.40 | $43.00 | $14.68 – $41.04 | 21 |
| Diagnostic anoscopy & biopsy CPT 46607 | not published | not published | $1,101.92 – $4,396.00 | 17 |
| Diagnostic digital breast tomosynthesis bil CPT 77062 | $93.60 | $117.00 | $14.09 – $163.85 | 23 |
| Diagnostic digital breast tomosynthesis unil CPT 77061 | $60.80 | $76.00 | $14.09 – $163.85 | 23 |
| Diagnostic laryngoscopy 31575 CPT 31575 | $617.60 | $772.00 | $86.25 – $1,131.20 | 22 |
| Diagnostic Mammogram (both breasts) CPT 77066 | $208.00 | $564.00 | $100.45 – $632.62 | 24 |
| Diagnostic Mammogram (one breast) CPT 77065 | $222.00 | $499.00 | $78.86 – $493.29 | 24 |
| Dialysis one evaluation CPT 90945 | $960.00 | $1,200.00 | $43.75 – $736.10 | 16 |
| Diazepam 5 mg/ml injection solution (wrapper) HCPCS J3360 | $300.80 | $376.00 | $11.16 – $49.14 | 10 |
| Dicyclomine injection HCPCS J0500 | $192.00 | $240.00 | $8.62 – $45.01 | 9 |
| Diffusing capacity CPT 94729 | $477.60 | $597.00 | $49.43 – $134.44 | 7 |
| Digoxin 250 mcg/ml (0.25 mg/ml) injection solution HCPCS J1160 | $38.80 | $48.50 | $4.15 – $30.27 | 10 |
| Digoxin total therapeutic drug level CPT 80162 | $55.20 | $69.00 | $13.28 – $60.29 | 25 |
| Dihydroergotamine 0.05 mg/ml IV syringe - cnr HCPCS J1110 | $556.20 | $695.25 | $45.57 – $310.62 | 10 |
| Dilate biliary duct/ampulla CPT 47542 | $3,115.20 | $3,894.00 | $136.64 – $371.65 | 7 |
| Diltiazem 5 mg/ml intravenous solution HCPCS J1163 | $130.00 | $162.50 | $0.04 – $12.80 | 9 |
| Diphenhydramine 50 mg/ml injection (wrapper) HCPCS J1200 | $39.20 | $49.00 | $0.57 – $2.88 | 10 |
| Disability dlco CPT 94727 | $299.20 | $374.00 | $39.45 – $270.46 | 21 |
| Dna antibody native/double stranded CPT 86225 | $57.60 | $72.00 | $13.74 – $89.43 | 25 |
| Dobutamine 250 mg/20 ml (12.5 mg/ml) intravenous solution HCPCS J1250 | $443.00 | $553.75 | $7.68 – $57.05 | 9 |
| Dopamine 40 mg/ml intravenous solution (wrapper) HCPCS J1265 | $130.80 | $163.50 | $0.90 – $27.86 | 10 |
| Doppler echo complete CPT 93320 | $1,340.80 | $1,676.00 | $75.66 – $205.80 | 7 |
| Doppler upper/lower extremity arteries complete bilateral CPT 93923 | $1,152.80 | $1,441.00 | $114.44 – $311.27 | 21 |
| Doppler upper/lower extremity arteries limited bilateral CPT 93922 | $514.40 | $643.00 | $60.99 – $222.83 | 21 |
| Doxycycline hyclate 100 mg intravenous powder for solution HCPCS J1271 | $162.80 | $203.50 | $0.12 – $42.00 | 10 |
| Drainage absc/cyst/hmtma/vestibule mouth smpl CPT 40800 | $496.80 | $621.00 | $33.13 – $1,216.29 | 22 |
| Drainage external ear complex 69005 CPT 69005 | $2,546.40 | $3,183.00 | $171.85 – $5,670.70 | 8 |
| Drainage external ear simple 69000 CPT 69000 | $700.80 | $876.00 | $53.75 – $1,216.29 | 22 |
| Drainage of kidney lesion CPT 50390 | $1,200.00 | $1,500.00 | $114.44 – $4,109.00 | 22 |
| Drain blood from under nail 11740 CPT 11740 | $284.00 | $355.00 | $30.00 – $1,131.20 | 22 |
| Drain cath image guided visceral pq CPT 49405 | $1,820.00 | $2,275.00 | $216.71 – $4,109.00 | 8 |
| Drain finger abscess;simple 26010 CPT 26010 | $525.60 | $657.00 | $33.13 – $1,131.20 | 22 |
| Dress/debride pt-thick burn/<5% bs 16020 CPT 16020 | $520.80 | $651.00 | $25.00 – $1,131.20 | 22 |
| Drng hand tendon sheath 26020 CPT 26020 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Drng of eyelid abscess 67700 CPT 67700 | $914.40 | $1,143.00 | $48.13 – $2,402.40 | 18 |
| Droperidol 2.5 mg/ml injection solution HCPCS J1790 | $129.60 | $162.00 | $5.56 – $34.58 | 10 |
| Drug assay rufinamide CPT 80210 | $83.20 | $104.00 | $18.72 – $123.08 | 22 |
| Drug assay vedolizumab CPT 80280 | $144.80 | $181.00 | $28.93 – $175.11 | 21 |
| Drug assay voriconazole CPT 80285 | $82.40 | $103.00 | $27.11 – $123.08 | 25 |
| Drug test def 1-7 classes HCPCS G0480 | $316.80 | $396.00 | $17.34 – $519.51 | 25 |
| Drug test(s) presumptive any class instrument chemistry analyzers CPT 80307 | $172.00 | $215.00 | $62.14 – $282.12 | 25 |
| Drvvt confirm - quest CPT 85597 | $120.80 | $151.00 | $17.98 – $84.46 | 25 |
| Duplex scan bilateral study 93985 CPT 93985 | $665.60 | $832.00 | $238.78 – $697.82 | 21 |
| Duplex scan unilateral study 93986 CPT 93986 | $665.60 | $832.00 | $105.04 – $405.28 | 21 |
| Dup scan/hemodialysis access 93990 CPT 93990 | $665.60 | $832.00 | $105.04 – $314.47 | 21 |
| Dup scan/lwr xtr vasc stdy bilat 93924 CPT 93924 | $1,488.80 | $1,861.00 | $126.21 – $343.30 | 21 |
| Dup scan/ue art/graft/bilat/comp 93930 CPT 93930 | $1,064.80 | $1,331.00 | $176.95 – $481.30 | 21 |
| Dxa bone density axl vrt fx CPT 77085 | $501.60 | $627.00 | $38.22 – $602.31 | 21 |
| Dx bronchoscope/brush 31623 CPT 31623 | $3,598.40 | $4,498.00 | $168.94 – $4,396.00 | 8 |
| Dx bronchoscope/lavage 31624 CPT 31624 | $3,598.40 | $4,498.00 | $168.94 – $4,396.00 | 8 |
| Dx bronchoscope/wash 31622 CPT 31622 | $3,598.40 | $4,498.00 | $167.33 – $4,396.00 | 8 |
| Ear irrigation 69209 CPT 69209 | $277.60 | $347.00 | $12.00 – $1,131.20 | 22 |
| Ecg 12 lead tracing only CPT 93005 | $314.40 | $393.00 | $13.08 – $102.69 | 21 |
| Echocardiogram (Heart Ultrasound) CPT 93306 | $3,730.40 | $4,663.00 | $176.28 – $947.84 | 21 |
| Echocardiography doppler color flow mapping CPT 93325 | $1,276.80 | $1,596.00 | $23.23 – $63.17 | 7 |
| Echocardiography transthoracic 2d followup/limited CPT 93308 | $1,780.80 | $2,226.00 | $45.63 – $417.87 | 21 |
| Echocardiograpy doppler follow up/limited study CPT 93321 | $568.00 | $710.00 | $35.38 – $96.22 | 7 |
| Echo guide for artery repair CPT 76936 | $1,456.00 | $1,820.00 | $25.32 – $1,719.60 | 23 |
| Echo stress CPT 93350 | $1,440.00 | $1,800.00 | $95.63 – $947.84 | 21 |
| Echo tee probe placement image acquisition interpretation & report CPT 93312 | $3,646.40 | $4,558.00 | $299.36 – $947.84 | 21 |
| Echo transesophageal intraop CPT 93318 | $3,743.20 | $4,679.00 | $411.23 – $1,365.77 | 17 |
| Echo transthoracic CPT 93303 | $2,035.20 | $2,544.00 | $196.56 – $947.84 | 21 |
| Echo transthoracic CPT 93304 | $1,244.00 | $1,555.00 | $45.63 – $947.84 | 21 |
| Echo tte 2d comp wo ctrst wo clr/dplr CPT 93307 | $2,407.20 | $3,009.00 | $175.48 – $1,365.77 | 21 |
| Eeg monitor/record/awake/drowsy 95816 CPT 95816 | $956.80 | $1,196.00 | $28.13 – $538.32 | 21 |
| Eeg over 1 hour 95813 - 26 CPT 95813 | $604.00 | $755.00 | $146.09 – $538.32 | 21 |
| Eeg recording awake and asleep CPT 95819 | $1,076.80 | $1,346.00 | $28.13 – $538.32 | 21 |
| Egd control bleeding any CPT 43255 | not published | not published | $1,101.92 – $5,667.92 | 3 |
| Egd dilate stricture CPT 43245 | not published | not published | $1,101.92 – $5,667.92 | 3 |
| Egd remove lesion snare CPT 43251 | not published | not published | $1,101.92 – $5,667.92 | 3 |
| Ehrlicha chaffeensis amp prb CPT 87484 | $162.40 | $203.00 | $35.09 – $159.31 | 25 |
| Electrical stimulation/unattended 97014 CPT 97014 | $142.40 | $178.00 | $11.82 – $136.00 | 21 |
| Electroacous eval hear aid/biaural 92595 CPT 92595 | $165.60 | $207.00 | $15.00 – $40.80 | 7 |
| Electrolyte panel CPT 80051 | $29.60 | $37.00 | $7.01 – $31.83 | 25 |
| Electron microscopy diagnostic CPT 88348 | $604.00 | $755.00 | $24.52 – $2,457.87 | 25 |
| Embo or occlude vascular arterial s&i CPT 37242 | $29,632.80 | $37,041.00 | $511.18 – $28,500.00 | 8 |
| Embo or occlude vascular hemorrhage s&i CPT 37244 | $36,448.00 | $45,560.00 | $710.98 – $28,500.00 | 8 |
| Embo or occlude vascular tumor/organ/infarct s&i CPT 37243 | $6,191.20 | $7,739.00 | $609.50 – $28,500.00 | 8 |
| Embo or occlude vascular venous s&i CPT 37241 | $20,976.00 | $26,220.00 | $457.78 – $28,500.00 | 8 |
| Emb without cervical dilation 58100 CPT 58100 | $529.60 | $662.00 | $63.75 – $1,131.20 | 22 |
| Endo abl/incom vein/ext/rad fre/#1 36475 CPT 36475 | $3,156.00 | $3,945.00 | $362.23 – $12,006.00 | 3 |
| Endoscopy swallow (fees) vid CPT 92612 | $278.40 | $348.00 | $78.60 – $319.04 | 21 |
| Enoxaparin 30 mg/0.3 ml subcutaneous syringe HCPCS J1650 | $210.40 | $263.00 | $0.64 – $5.89 | 10 |
| Epinephrine 0.1 mg/ml injection syringe HCPCS J0168 | $133.80 | $167.25 | $2.76 – $85.07 | 9 |
| Epinephrine 1 mg/ml im kit - adult HCPCS J0169 | $1,285.40 | $1,606.75 | $1.47 – $45.44 | 9 |
| Episiotomy/vag rpr oth/thn attending phys 59300 CPT 59300 | $4,389.60 | $5,487.00 | $166.18 – $6,066.00 | 2 |
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.