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 |
|---|---|---|---|---|
| Epoetin alfa-epbx 40,000 unit/ml injection solution HCPCS Q5106 | $1,118.80 | $1,398.50 | $8.36 – $52.51 | 25 |
| Epoetin alfa in ns IV syringe 100 unit/ml (neo/ped) - cnr HCPCS J0885 | $1,939.80 | $2,424.75 | $9.27 – $571.42 | 25 |
| Epoprostenol (arginine) 1 mg in 50 ml ns inhalation syringe - cnr HCPCS J1325 | $720.40 | $900.50 | $17.57 – $168.84 | 10 |
| Epstein barr early antigen antibody CPT 86663 | $55.20 | $69.00 | $13.12 – $73.50 | 25 |
| Epstein barr nuclear antigen antibody CPT 86664 | $63.20 | $79.00 | $15.29 – $71.88 | 25 |
| Epstein barr viral capsid antigen antibody igm CPT 86665 | $76.00 | $95.00 | $18.14 – $118.06 | 25 |
| Ertapenem 1000 mg/10 ml IV (dilution #1) desensitization - cnr HCPCS J1335 | $295.80 | $369.75 | $10.70 – $65.94 | 10 |
| ER Visit (level 1, minor) CPT 99281 | $511.20 | $639.00 | $25.56 – $152.22 | 20 |
| ER Visit (level 2) CPT 99282 | $668.00 | $835.00 | $43.75 – $273.75 | 20 |
| ER Visit (level 3) CPT 99283 | $1,226.40 | $1,533.00 | $98.75 – $478.66 | 20 |
| ER Visit (level 4) CPT 99284 | $1,810.40 | $2,263.00 | $153.75 – $736.10 | 20 |
| ER Visit (level 5, high severity) CPT 99285 | $1,844.80 | $2,306.00 | $241.25 – $1,059.85 | 20 |
| Erythromycin in ns IV syringe 5 mg/ml (neo/ped) - cnr HCPCS J1364 | $703.20 | $879.00 | $49.07 – $240.16 | 10 |
| Esmolol 2,500 mg/250 ml (10 mg/ml) IV wrapper osm only HCPCS J1805 | $1,156.60 | $1,445.75 | $0.24 – $9.80 | 10 |
| Established Patient Office Visit (level 1) CPT 99211 | $526.40 | $658.00 | $50.00 – $222.78 | 21 |
| Established Patient Office Visit (level 2) CPT 99212 | $675.20 | $844.00 | $50.00 – $222.78 | 21 |
| Established Patient Office Visit (level 3) CPT 99213 | $445.60 | $557.00 | $50.00 – $222.78 | 21 |
| Established Patient Office Visit (level 4) CPT 99214 | $814.40 | $1,018.00 | $50.00 – $222.78 | 21 |
| Established Patient Office Visit (level 5) CPT 99215 | $1,076.00 | $1,345.00 | $50.00 – $222.78 | 21 |
| Estradiol total CPT 82670 | $116.80 | $146.00 | $26.88 – $126.85 | 25 |
| Estrogens total-sendout CPT 82672 | $90.40 | $113.00 | $17.40 – $98.52 | 25 |
| Ethylene glycol -sendout CPT 82693 | $62.40 | $78.00 | $14.04 – $67.65 | 20 |
| Etonogestrel implant system HCPCS J7307 | $4,771.20 | $5,964.00 | $796.20 – $4,664.19 | 10 |
| Evaluation of speech fluency 92521 CPT 92521 | $400.80 | $501.00 | $50.00 – $221.25 | 20 |
| Evoked auditory tst complete CPT 92588 | $302.40 | $378.00 | $72.36 – $538.32 | 21 |
| Evoked oa emissions ltd CPT 92587 | $151.20 | $189.00 | $42.01 – $538.32 | 21 |
| Evoked potentials auditory screening automated analysis CPT 92650 | $94.40 | $118.00 | $27.69 – $75.31 | 7 |
| Exc arm/elbo les sc >=3cm 24071 CPT 24071 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Exc bartholins gland/cyst CPT 56740 | not published | not published | $1,101.92 – $9,499.98 | 3 |
| Exc ben+marg excep skin tag feenlm 1.1-2cm 11442 CPT 11442 | not published | not published | $695.02 – $2,620.00 | 17 |
| Exc ben+marg excep skin tag feenlm 2.1-3cm 11443 CPT 11443 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Exc ben+marg excep skin tag snhfg 0.6-1cm 11421 CPT 11421 | not published | not published | $1,101.92 – $5,834.62 | 3 |
| Exc ben+marg excep skin tag snhfg 2.1-3cm 11423 CPT 11423 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Exc ben+marg excep skin tag snhfg >4cm 11426 CPT 11426 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Exc ben+marg excep skin tag tal 0.6-1cm 11401 CPT 11401 | not published | not published | $1,101.92 – $5,834.62 | 3 |
| Exc ben+marg excep skin tag tal 2.1-3/>cm 11403 CPT 11403 | not published | not published | $695.02 – $2,620.00 | 17 |
| Exc chest wall tumor w/ribs 21601 CPT 21601 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Exc forearm les sc 3 cm/> CPT 25071 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Exc hand les sc < 1.5 cm CPT 26115 | not published | not published | $1,101.92 – $6,066.00 | 3 |
| Exc hand tum deep 1.5 cm/> CPT 26113 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Exchange biliary drg cath CPT 47536 | $6,028.00 | $7,535.00 | $150.23 – $7,441.00 | 8 |
| Exchange drainage catheter CPT 49423 | $2,845.60 | $3,557.00 | $73.50 – $4,396.00 | 8 |
| Exchange nephrostomy cath CPT 50435 | $3,552.80 | $4,441.00 | $102.75 – $2,620.00 | 8 |
| Exc hidradenitis ing simpl 11462 CPT 11462 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Exc im tumor/foot/toe < 1.5 cm 28045 CPT 28045 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Excision benign lesion scalp/neck/hands/feet/genitalia 1.1 - 2.0 cm CPT 11422 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Excision benign lesion trunk/arms/legs 1.1 - 2.0 cm CPT 11402 | not published | not published | $695.02 – $2,571.00 | 17 |
| Excision benign lesion trunk/arms/legs > 4.0 cm CPT 11406 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Excision breast lesion CPT 19125 | not published | not published | $1,101.92 – $11,441.35 | 3 |
| Excision graft extremity CPT 35903 | not published | not published | $1,101.92 – $9,404.28 | 3 |
| Exc malig feenl >4cm 11646 CPT 11646 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Exc malig snhfg 0.5cm or less 11620 CPT 11620 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Exc malig snhfg 2.1-3 cm 11623 CPT 11623 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Exc/pilonidal cyst/sinus/simple 11770 CPT 11770 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Exc skn hdrdnt ax smpl/ntrm CPT 11450 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Exc snhfg mal+mrg 3.1-4 11624 CPT 11624 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Exc thigh/knee les sc<3cm 27327 CPT 27327 | not published | not published | $1,101.92 – $6,066.00 | 3 |
| Exc tr-ext mal+marg tal >4 cm 11606 CPT 11606 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Exc vagina lesion 57135 CPT 57135 | not published | not published | $1,101.92 – $9,499.98 | 3 |
| Ex sq tumor/face or scalp < 2 cm 21011 CPT 21011 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Ex sq tumor/face or scalp 2 cm/> 21012 CPT 21012 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| External chromosome analysis 20-25 cells CPT 88264 | $601.60 | $752.00 | $18.48 – $656.53 | 25 |
| External tissue culture neoplastic disorders bone marrow/blood cells CPT 88237 | $604.00 | $755.00 | $92.74 – $652.63 | 25 |
| Extractable nuclear antigen/antibody any method each antibody centromere CPT 86235 | $75.20 | $94.00 | $17.93 – $116.72 | 25 |
| Facial bones <3 CPT 70140 | $224.00 | $280.00 | $18.91 – $497.84 | 24 |
| Factor ix CPT 85250 | $111.20 | $139.00 | $6.25 – $86.44 | 25 |
| Factor ix recombinant nos HCPCS J7195 | $3,835.80 | $4,794.75 | $2.01 – $3,237.50 | 24 |
| Factor viii CPT 85240 | $134.40 | $168.00 | $16.25 – $81.27 | 25 |
| Famotidine in ns IV syringe 0.4 mg/ml (neo/ped) - cnr HCPCS J1308 | $36.40 | $45.50 | $0.01 – $2.80 | 10 |
| Fat/lipids feces qualitative CPT 82705 | $21.60 | $27.00 | $5.10 – $23.94 | 25 |
| Fatty acids nonesterified CPT 82725 | $78.40 | $98.00 | $16.48 – $85.22 | 25 |
| Felbamate (felbatol(r)) - sendout CPT 80167 | $92.80 | $116.00 | $13.98 – $84.63 | 22 |
| Fem/popl revasc w/stent CPT 37226 | $16,129.60 | $20,162.00 | $6,420.00 – $28,500.00 | 2 |
| Fentanyl citrate (pf) 50 mcg/ml injection for compounding (wrapper) HCPCS J3010 | $81.40 | $101.75 | $0.83 – $3.67 | 10 |
| Ferritin CPT 82728 | $40.00 | $71.00 | $13.63 – $61.88 | 26 |
| Fetal hemoglobin (kleihauer betke) CPT 85460 | $54.40 | $68.00 | $7.73 – $50.38 | 25 |
| Fetal hemoglobin rosette CPT 85461 | $54.40 | $68.00 | $9.36 – $43.20 | 25 |
| Fetal non stress test CPT 59025 | $490.40 | $613.00 | $21.88 – $1,131.20 | 22 |
| Fibrin degradation d dimer quantitative CPT 85379 | $60.80 | $76.00 | $10.18 – $52.70 | 25 |
| Fibrin degradation products CPT 85362 | $37.60 | $47.00 | $6.89 – $44.85 | 25 |
| Fibrinogen activity CPT 85384 | $64.00 | $80.00 | $9.72 – $55.28 | 25 |
| Fine needle aspiration biopsy w/us gdn; ea addtl 10006 CPT 10006 | $1,326.40 | $1,658.00 | $50.89 – $138.41 | 7 |
| Flecainide (tambocor)-sendout CPT 80181 | $77.60 | $97.00 | $13.98 – $84.63 | 22 |
| Fl exam g/colon tube w contrast CPT 49465 | $488.00 | $610.00 | $29.68 – $1,131.20 | 22 |
| Flow cytometry marker each additional CPT 88185 | $124.80 | $156.00 | $22.83 – $105.21 | 11 |
| Flow cytometry one marker technical component CPT 88184 | $124.80 | $156.00 | $46.43 – $1,027.44 | 25 |
| Fluconazole 200 mg/100 ml in sod. chloride (iso) intravenous piggyback HCPCS J1450 | $86.60 | $108.25 | $1.72 – $12.53 | 10 |
| Fluidotherapy charges pt CPT 97022 | $141.60 | $177.00 | $14.79 – $136.00 | 21 |
| Fluorescent antibody titer dna CPT 86256 | $49.60 | $62.00 | $11.39 – $56.93 | 25 |
| Fluoroguide for spine inject 77003-26 CPT 77003 | $380.80 | $476.00 | $29.08 – $170.99 | 8 |
| Fluoroguide needle placement CPT 77002 | $332.80 | $416.00 | $41.10 – $188.33 | 8 |
| Fluoroscopy up to 1 hour CPT 76000 | $659.20 | $824.00 | $23.75 – $1,342.45 | 23 |
| Fna bx w/ct gdn 1st les CPT 10009 | $1,326.40 | $1,658.00 | $116.29 – $2,620.00 | 22 |
| Folic acid CPT 82746 | $45.00 | $77.00 | $14.70 – $66.74 | 25 |
| Folic acid 5 mg/ml injection solution HCPCS J1808 | $224.60 | $280.75 | $0.07 – $105.00 | 10 |
| Fomepizole 1 gram/ml intravenous solution HCPCS J1451 | $5,021.60 | $6,277.00 | $7.40 – $4,511.50 | 21 |
| Fondaparinux sodium HCPCS J1652 | $293.00 | $366.25 | $0.78 – $15.05 | 9 |
| Foot X-ray CPT 73630 | $348.00 | $435.00 | $19.80 – $497.84 | 24 |
| Foreskn manip w/lss preputial ads+stretching 54450 CPT 54450 | $724.80 | $906.00 | $163.08 – $1,131.20 | 18 |
| Fosaprepitant 150 mg intravenous powder for solution HCPCS J1453 | $197.40 | $246.75 | $11.55 – $63.00 | 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.