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 |
|---|---|---|---|---|
| Fresh frozen plasma frozen within 8 hours of collection each unit HCPCS P9017 | $376.00 | $470.00 | $37.50 – $147.51 | 21 |
| Fructosamine glycated protein CPT 82985 | $69.60 | $87.00 | $16.76 – $76.09 | 25 |
| Furosemide 10 mg/ml injection solution HCPCS J1938 | $38.80 | $48.50 | $0.02 – $6.40 | 9 |
| Gadobutrol 1 mmol/ml intravenous solution (wrapper) HCPCS A9585 | $1.60 | $2.00 | $0.67 – $0.92 | 3 |
| Gadopentetate dimeglumine 469.01 mg/ml (46.9 %) intravenous (wrapper) HCPCS A9579 | $10.40 | $13.00 | $4.54 – $5.22 | 3 |
| Gadoxetate 0.25 mmol/ml (181.43 mg/ml) intravenous solution HCPCS A9581 | $51.20 | $64.00 | $12.40 – $51.49 | 3 |
| Gammaglobulin iga CPT 82784 | $35.00 | $49.00 | $9.30 – $43.69 | 25 |
| Gammaglobulin ige CPT 82785 | $68.00 | $85.00 | $16.46 – $74.73 | 25 |
| Gamma glutamyltransferase CPT 82977 | $29.60 | $37.00 | $7.20 – $32.69 | 25 |
| Gamunex-c/gammaked HCPCS J1561 | $4,813.00 | $6,016.25 | $53.12 – $3,073.92 | 25 |
| Gemcitabine 1 gram intravenous solution HCPCS J9201 | $220.20 | $275.25 | $3.39 – $52.30 | 10 |
| General health panel CPT 80050 | $70.00 | $250.00 | $54.86 – $149.23 | 9 |
| Gentamicin 10 mg/ml liquid compound - enteral use only HCPCS J1580 | $30.60 | $38.25 | $1.68 – $8.65 | 10 |
| Gentamicin peak therapeutic drug level CPT 80170 | $68.00 | $85.00 | $15.00 – $74.37 | 25 |
| Ghs abscess perianal iandd CPT 46050 | $934.40 | $1,168.00 | $94.58 – $4,109.00 | 22 |
| Ghs alpha thalasemia, 7 deletions CPT 81257 | $408.80 | $511.00 | $102.26 – $692.61 | 25 |
| Ghs bladder cath - complex-foley CPT 51703 | $651.20 | $814.00 | $93.26 – $1,131.20 | 22 |
| Ghs change cysto/gastrost CPT 43762 | $950.40 | $1,188.00 | $38.88 – $1,209.00 | 22 |
| Ghs chlamydia pneumoniae by pcr (arup) (306630) CPT 87486 | $145.60 | $182.00 | $32.67 – $159.31 | 25 |
| Ghs closd tx interphalang jt disloc w/ma CPT 26770 | $699.20 | $874.00 | $45.63 – $1,131.20 | 22 |
| Ghs closed reduction ankle dislocation CPT 27840 | $1,020.00 | $1,275.00 | $111.88 – $2,448.60 | 22 |
| Ghs closed tx bimalleolar fracture w/manip CPT 27810 | $1,091.20 | $1,364.00 | $246.88 – $2,448.60 | 8 |
| Ghs closed tx tibial fracture w/manip CPT 27752 | $1,368.00 | $1,710.00 | $291.88 – $5,670.70 | 8 |
| Ghs closure surg wound/dehiscence-13160 CPT 13160 | not published | not published | $1,101.92 – $6,066.00 | 17 |
| Ghs cl tx metacarpophal disloc without anes CPT 26700 | $462.40 | $578.00 | $48.75 – $1,131.20 | 22 |
| Ghs community re-entry 15 minutes CPT 97537 | $120.80 | $151.00 | $30.52 – $56.80 | 20 |
| Ghs conjunctiva foreign body-superf bil CPT 65205 | $504.00 | $630.00 | $34.38 – $1,131.20 | 18 |
| Ghs corneal fb without slit lamp bilat CPT 65220 | $601.60 | $752.00 | $33.13 – $1,131.20 | 22 |
| Ghs corneal fb with slit lamp bilat CPT 65222 | $606.40 | $758.00 | $32.50 – $1,131.20 | 22 |
| Ghs dislocation elbow closed treatment CPT 24600 | $521.60 | $652.00 | $128.13 – $1,131.20 | 22 |
| Ghs ed therapeutic lp, drain csf w fluoro CPT 62329 | $1,209.60 | $1,512.00 | $115.21 – $2,620.00 | 22 |
| Ghs excision ingrown nail CPT 11765 | $294.40 | $368.00 | $62.50 – $1,131.20 | 22 |
| Ghs fb removal - incisional CPT 10121 | not published | not published | $1,101.92 – $4,841.06 | 3 |
| Ghs flow volume loop CPT 94375 | $453.60 | $567.00 | $39.34 – $538.32 | 21 |
| Ghs gastric intub aspiration lavage CPT 43753 | $456.00 | $570.00 | $20.64 – $538.32 | 21 |
| Ghs histoplasma antigen CPT 87385 | $55.20 | $69.00 | $12.42 – $71.69 | 20 |
| Ghs i and d perirectal abscess 46040 CPT 46040 | $5,948.00 | $7,435.00 | $135.63 – $6,956.60 | 22 |
| Ghs i and d pilonidal cyst complex CPT 10081 | $3,024.00 | $3,780.00 | $140.63 – $4,109.00 | 22 |
| Ghs i and d pilonidal cyst simple CPT 10080 | $569.60 | $712.00 | $45.00 – $1,216.29 | 22 |
| Ghs incision thrombosed ext hemorrhoid CPT 46083 | $734.40 | $918.00 | $51.25 – $1,131.20 | 22 |
| Ghs init tx 1st degree burn CPT 16000 | $605.60 | $757.00 | $22.50 – $1,131.20 | 22 |
| Ghs inj neurolytic other perph nerve CPT 64640 | not published | not published | $1,101.92 – $2,620.00 | 17 |
| Ghs insertion of needle - bone CPT 36680 | $904.80 | $1,131.00 | $61.88 – $1,131.20 | 22 |
| Ghs intermed repair 12.6 - 20.0 cm-12035 CPT 12035 | $1,440.80 | $1,801.00 | $115.00 – $1,131.20 | 22 |
| Ghs intro needle/intracath vein - 36000 CPT 36000 | $100.80 | $126.00 | $10.10 – $27.47 | 7 |
| Ghs irrigate corpora cavernosa for priapism CPT 54220 | $1,212.00 | $1,515.00 | $155.05 – $1,131.20 | 18 |
| Ghs IV thrombolytics - cerebral CPT 37195 | $804.00 | $1,005.00 | $180.90 – $1,131.20 | 18 |
| Ghs lac repair mouth.ant tong 2.5cm/less CPT 41250 | $496.80 | $621.00 | $39.38 – $1,131.20 | 22 |
| Ghs layer closure 2.5 cm or less - 12031 CPT 12031 | $618.40 | $773.00 | $30.63 – $1,131.20 | 22 |
| Ghs layer closure 2.5 cm or less - 12041 CPT 12041 | $618.40 | $773.00 | $30.63 – $1,131.20 | 22 |
| Ghs layer closure 2.5cm or less - 12051 CPT 12051 | $618.40 | $773.00 | $39.38 – $1,131.20 | 22 |
| Ghs layer closure 2.6 - 5.0 cm - 12052 CPT 12052 | $1,160.00 | $1,450.00 | $59.38 – $1,131.20 | 22 |
| Ghs layer closure 2.6 - 7.5 cm - 12042 CPT 12042 | $1,252.80 | $1,566.00 | $44.38 – $1,131.20 | 22 |
| Ghs layer closure 5.1 - 7.5 cm - 12053 CPT 12053 | $1,252.80 | $1,566.00 | $59.38 – $1,131.20 | 22 |
| Ghs layer closure 7.6 - 12.5 cm - 12034 CPT 12034 | $1,315.20 | $1,644.00 | $58.13 – $1,131.20 | 22 |
| Ghs layer closure 7.6 - 12.5 cm - 12044 CPT 12044 | $1,315.20 | $1,644.00 | $60.63 – $1,131.20 | 22 |
| Ghs layer closure 7.6 - 12.5 cm - 12054 CPT 12054 | $1,314.40 | $1,643.00 | $76.88 – $1,131.20 | 22 |
| Ghs mbp CPT 83873 | $71.20 | $89.00 | $17.20 – $78.09 | 25 |
| Ghs moderate sedation < 5 yr, 30 min CPT 99151 | $583.20 | $729.00 | $23.78 – $64.67 | 7 |
| Ghs moderate sedation, > 5 yr, 30 min, other CPT 99156 | $227.20 | $284.00 | $76.38 – $207.74 | 7 |
| Ghs moderate sedation ea addtl 15 min CPT 99153 | $155.20 | $194.00 | $10.41 – $28.32 | 7 |
| Ghs moderate sedation ea addtl 15 min, other CPT 99157 | $62.40 | $78.00 | $57.89 – $157.45 | 7 |
| Ghs musc test done w/n test comp CPT 95886 | $308.80 | $386.00 | $82.86 – $225.39 | 7 |
| Ghs musc tst done w/nerv tst lim CPT 95885 | $308.80 | $386.00 | $52.14 – $141.81 | 7 |
| Ghs nailbed repair/nail removal CPT 11760 | $956.80 | $1,196.00 | $28.75 – $2,402.40 | 22 |
| Ghs nerve block brachial plexus CPT 64415 | not published | not published | $1,101.92 – $9,694.44 | 3 |
| Ghs ng placement w fluoro guidance CPT 43752 | $368.00 | $460.00 | $82.80 – $689.82 | 17 |
| Ghs o2 saturation CPT 82810 | $40.80 | $51.00 | $9.77 – $44.36 | 25 |
| Ghs ot prosthetic training/15 min CPT 97761 | $118.40 | $148.00 | $38.66 – $67.66 | 20 |
| Ghs ot sensory integrative tech/15min CPT 97533 | $125.60 | $157.00 | $50.00 – $100.12 | 20 |
| Ghs peritonsillar abscess i andd CPT 42700 | $595.20 | $744.00 | $77.50 – $2,402.40 | 22 |
| Ghs plngl fx pm cl CPT 26725 | $452.00 | $565.00 | $96.25 – $1,131.20 | 22 |
| Ghs ppd (tb intradermal) CPT 86580 | $104.80 | $131.00 | $6.88 – $85.11 | 25 |
| Ghs prostatic acid phosphatase (mayo) CPT 84066 | $40.00 | $50.00 | $9.66 – $43.86 | 25 |
| Ghs protoporphyrins fract CPT 84202 | $60.00 | $75.00 | $14.35 – $67.46 | 25 |
| Ghs pr without cont pulse ox CPT 94625 | $284.00 | $355.00 | $58.68 – $102.69 | 16 |
| Ghs quinidine CPT 80194 | $60.80 | $76.00 | $14.60 – $66.28 | 25 |
| Ghs removal intranasal foreign body CPT 30300 | $505.60 | $632.00 | $28.13 – $222.83 | 21 |
| Ghs removal pharyngeal foreign body CPT 42809 | $135.20 | $169.00 | $81.25 – $689.82 | 21 |
| Ghs repair extensor tendon hand, ea tendon CPT 26410 | not published | not published | $1,101.92 – $8,551.40 | 3 |
| Ghs sensitivity (per antimicro) CPT 87184 | $30.40 | $38.00 | $7.48 – $33.96 | 25 |
| Ghs simple repair 12.6 - 20.0 cm - 12005 CPT 12005 | $1,310.40 | $1,638.00 | $115.00 – $1,131.20 | 22 |
| Ghs simple repair 20.1 - 30.0 cm - 12006 CPT 12006 | $1,545.60 | $1,932.00 | $115.00 – $1,131.20 | 22 |
| Ghs simple repair 5.1 - 7.5 cm - 12014 CPT 12014 | $1,215.20 | $1,519.00 | $59.38 – $1,131.20 | 22 |
| Ghs simple repair 7.6 - 12.5 cm - 12004 CPT 12004 | $1,248.80 | $1,561.00 | $60.63 – $1,131.20 | 22 |
| Ghs simple repair 7.6 - 12.5 cm - 12015 CPT 12015 | $1,248.80 | $1,561.00 | $76.88 – $1,131.20 | 22 |
| Ghs sleep study unattended CPT 95800 | $847.20 | $1,059.00 | $154.55 – $423.67 | 21 |
| Ghs st - eval for alt comm CPT 92567 | $140.80 | $176.00 | $15.00 – $67.85 | 21 |
| Ghs st - re-eval for alt comm CPT 92597 | $737.60 | $922.00 | $51.71 – $120.65 | 16 |
| Ghs superficial wnd dehiscence simp12020 CPT 12020 | $1,043.20 | $1,304.00 | $117.50 – $2,402.40 | 22 |
| Ghs urine, porphyrins quant CPT 84120 | $61.60 | $77.00 | $9.38 – $66.78 | 25 |
| Gi inhouse confirmation CPT 87045 | $39.20 | $49.00 | $8.63 – $47.63 | 25 |
| Glucagon hcl 1 mg/ml solution for injection HCPCS J1611 | $1,770.20 | $2,212.75 | $113.15 – $526.54 | 25 |
| Glucose 1 hr post dose CPT 82950 | $20.00 | $25.00 | $4.75 – $22.20 | 25 |
| Glucose blood quantitative CPT 82947 | $16.80 | $21.00 | $3.93 – $17.84 | 25 |
| Glucose body fluid CPT 82945 | $16.80 | $21.00 | $3.93 – $17.84 | 25 |
| Glucose tolerance test (gtt) 3 specimens CPT 82951 | $53.60 | $67.00 | $12.87 – $58.43 | 25 |
| Glucose tolerance test (gtt) >3 specimens each additional CPT 82952 | $16.80 | $21.00 | $3.92 – $17.80 | 25 |
| Glycopyrrolate 0.2 mg/ml injection solution HCPCS J1596 | $208.80 | $261.00 | $0.50 – $7.14 | 24 |
| Gonadotropin follicle stimulating hormone (fsh) CPT 83001 | $77.60 | $97.00 | $18.58 – $84.35 | 25 |
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.