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 |
|---|---|---|---|---|
| Gonadotropin luteinizing hormone (lh) CPT 83002 | $77.60 | $97.00 | $18.52 – $84.08 | 25 |
| Gu dilat ureter/urethra s&i CPT 74485 | $5,041.60 | $6,302.00 | $84.36 – $11,158.80 | 9 |
| Guided cath fluid drainage 10030 CPT 10030 | $1,224.80 | $1,531.00 | $156.60 – $1,216.29 | 22 |
| Guid loc target vol rad tx CPT 77387 | $1,685.60 | $2,107.00 | $99.43 – $270.44 | 7 |
| Haloperidol decanoate 50 mg/ml intramuscular solution HCPCS J1631 | $226.20 | $282.75 | $4.77 – $32.27 | 10 |
| Haloperidol lactate 5 mg/ml injection solution HCPCS J1630 | $44.40 | $55.50 | $0.61 – $2.73 | 10 |
| Hand X-ray CPT 73130 | $369.60 | $462.00 | $20.13 – $497.84 | 24 |
| Haptoglobin quantitative CPT 83010 | $45.00 | $66.00 | $12.58 – $57.11 | 25 |
| Hba1/hba2 full gene sequence CPT 81259 | $1,240.00 | $1,550.00 | $73.15 – $2,724.00 | 20 |
| Hbot, full body chamber, 30m HCPCS G0277 | $591.20 | $739.00 | $54.86 – $238.39 | 21 |
| Hc fl sm bowel enteroclss tube w kub double contrast CPT 74251 | $867.20 | $1,084.00 | $79.06 – $1,006.60 | 23 |
| Hcg quantitative CPT 84702 | $55.00 | $78.00 | $15.05 – $68.33 | 26 |
| Hc hearing aid chck binaurl CPT 92593 | $85.60 | $107.00 | $15.00 – $40.80 | 7 |
| Hc hearing aid chck monarl CPT 92592 | $67.20 | $84.00 | $11.25 – $30.60 | 7 |
| Head CT scan (with and without contrast) CPT 70470 | $569.00 | $2,645.00 | $175.85 – $1,006.60 | 24 |
| Head CT scan (with contrast) CPT 70460 | $478.00 | $2,362.00 | $167.50 – $1,006.60 | 24 |
| Head CT scan (without contrast) CPT 70450 | $296.00 | $1,610.00 | $105.04 – $602.31 | 24 |
| Hematocrit CPT 85014 | $17.60 | $22.00 | $2.37 – $10.98 | 25 |
| Hemodialysis one evaluation CPT 90935 | $830.40 | $1,038.00 | $46.80 – $1,209.60 | 17 |
| Hemoglobin CPT 85018 | $17.60 | $22.00 | $2.37 – $10.98 | 25 |
| Hemoglobin methemoglobin quantitative CPT 83050 | $34.40 | $43.00 | $3.75 – $37.23 | 25 |
| Hemoglobin plasma CPT 83051 | $30.40 | $38.00 | $4.38 – $33.19 | 25 |
| Hemophilus influenza antibdy CPT 86684 | $65.60 | $82.00 | $15.84 – $95.67 | 25 |
| Heparin assay CPT 85520 | $86.40 | $108.00 | $8.16 – $59.43 | 25 |
| Heparin bolus from bag HCPCS J1644 | $172.40 | $215.50 | $0.22 – $3.85 | 10 |
| Hepatitis a antibody igm CPT 86709 | $46.40 | $58.00 | $11.26 – $73.29 | 25 |
| Hepatitis b core antibody igm CPT 86705 | $48.80 | $61.00 | $11.77 – $55.25 | 25 |
| Hepatitis b core antibody total CPT 86704 | $49.60 | $62.00 | $12.05 – $54.71 | 25 |
| Hepatitis b immune globulin greater than 1,560 units/5 ml im solution CPT 90371 | $4,936.20 | $6,170.25 | $12.50 – $590.17 | 26 |
| Hepatitis b surface antibody CPT 86706 | $44.80 | $56.00 | $10.74 – $69.91 | 25 |
| Hepatitis c antibody CPT 86803 | $55.00 | $74.00 | $14.27 – $64.79 | 26 |
| Hepatobiliary system imaging CPT 78226 | $1,713.60 | $2,142.00 | $268.09 – $2,259.58 | 23 |
| Herpes simplex type 1 antibody igg CPT 86695 | $55.20 | $69.00 | $13.19 – $61.95 | 25 |
| Herpes simplex type 2 antibody igg CPT 86696 | $80.80 | $101.00 | $19.35 – $87.85 | 25 |
| Heterophile antibodies screening CPT 86308 | $21.60 | $27.00 | $5.18 – $33.70 | 25 |
| Hip X-ray CPT 73502 | $453.60 | $567.00 | $27.96 – $497.84 | 24 |
| Hla ii typing 1 loc hr CPT 81382 | $514.40 | $643.00 | $123.68 – $561.51 | 24 |
| Hla i typing high res 1 allele grp ea CPT 81381 | $575.20 | $719.00 | $129.03 – $771.35 | 24 |
| Homocysteine CPT 83090 | $75.20 | $94.00 | $17.92 – $81.36 | 25 |
| Homogenization tissue CPT 87176 | $24.00 | $30.00 | $5.88 – $38.30 | 25 |
| Hpv combo assay ca screen HCPCS G0476 | $150.40 | $188.00 | $35.09 – $159.31 | 26 |
| H pylori (c-13) breath CPT 83013 | $280.00 | $350.00 | $63.39 – $305.81 | 25 |
| Hyaluronidase, human recombinant 150 unit/ml injection solution HCPCS J3473 | $598.80 | $748.50 | $0.39 – $189.00 | 10 |
| Hydralazine 20 mg/ml injection solution HCPCS J0360 | $165.00 | $206.25 | $4.26 – $18.73 | 10 |
| Hydration IV infusion each additional hour CPT 96361 | $160.00 | $200.00 | $11.25 – $79.77 | 21 |
| Hydration IV infusion initial 31minutes - 1 hour CPT 96360 | $664.00 | $830.00 | $39.54 – $364.21 | 21 |
| Hydrocortisone in ns IV syringe 1 mg/ml (neo/ped) - cnr HCPCS J1720 | $264.60 | $330.75 | $16.18 – $72.03 | 10 |
| Hydromorphone 0.2 mg/ml in 0.9% nacl IV pca opioid naive - 4 hr dose limit (wrapper) HCPCS J1171 | $64.00 | $80.00 | $0.10 – $2.45 | 10 |
| Hydromorphone 20-0.9 mg/100ml-% soln 100 ml cartridge HCPCS J7999 | $215.40 | $269.25 | $15.40 – $68.22 | 9 |
| Hysterosalpingography s&i CPT 74740 | $784.00 | $980.00 | $53.77 – $1,342.45 | 19 |
| Iadna legionella pneumophila amplified probe tq CPT 87541 | $145.60 | $182.00 | $26.32 – $159.31 | 21 |
| I&d/bursa/foot 28001 CPT 28001 | $2,223.20 | $2,779.00 | $49.38 – $4,109.00 | 8 |
| Igh@ var region somatic mutation analy CPT 81263 | $1,225.60 | $1,532.00 | $128.28 – $1,337.12 | 25 |
| Ihc/icc per specimen each additional single antibody stain CPT 88341 | $183.20 | $229.00 | $63.89 – $374.64 | 11 |
| Ihc/icc per specimen each multiplex antibody stain CPT 88344 | $761.60 | $952.00 | $99.47 – $1,027.44 | 25 |
| Ihc/icc per specimen initial single antibody stain CPT 88342 | $244.00 | $305.00 | $43.93 – $488.22 | 25 |
| Immobilizer shldr dlx str 24-36in med HCPCS L1830 | $159.20 | $199.00 | $68.11 – $119.19 | 16 |
| Immune complex assay CPT 86332 | $101.60 | $127.00 | $15.99 – $110.64 | 25 |
| Immunoassay tumor antigen quantitative ca 125 CPT 86304 | $85.00 | $108.00 | $20.81 – $135.44 | 25 |
| Immunoassay tumor antigen quantitative ca 19-9 CPT 86301 | $85.00 | $108.00 | $20.81 – $135.44 | 25 |
| Immunodiff gel qual ea antigen/ab CPT 86331 | $49.60 | $62.00 | $10.00 – $78.02 | 25 |
| Immunofixation electrophoresis serum CPT 86334 | $92.80 | $116.00 | $11.33 – $101.42 | 25 |
| Immunofluorescence per specimen each additional single antibody stain CPT 88350 | $90.40 | $113.00 | $24.55 – $504.08 | 11 |
| Immunofluorescence per specimen initial single antibody stain CPT 88346 | $55.20 | $69.00 | $24.25 – $657.80 | 25 |
| Immunoglobulin assay CPT 86023 | $62.40 | $78.00 | $12.46 – $69.22 | 25 |
| Implant neuroelectrodes CPT 64561 | not published | not published | $1,101.92 – $19,609.01 | 3 |
| In-111 autol wbc diag per dose HCPCS A9570 | $6,836.00 | $8,545.00 | $773.54 – $15,029.56 | 20 |
| In-111 pentetreotide HCPCS A9572 | $5,104.80 | $6,381.00 | $1,148.58 – $13,815.90 | 20 |
| Incision & drainage hematoma/seroma/fluid collection CPT 10140 | $3,214.40 | $4,018.00 | $29.38 – $4,841.06 | 9 |
| Incision of foot fascia CPT 28008 | $4,448.00 | $5,560.00 | $170.63 – $6,066.00 | 8 |
| Incisn of toe tndn CPT 28010 | $2,519.20 | $3,149.00 | $163.75 – $5,670.70 | 8 |
| Indigotindisulfonate 8 mg/ml soln 5 ml ampule HCPCS J9220 | $2,447.20 | $3,059.00 | $9.96 – $1,274.88 | 19 |
| Infect ag drug suscept pheno predict CPT 87900 | $542.40 | $678.00 | $14.06 – $591.79 | 25 |
| Infect ag genotype na hiv-1 other region CPT 87906 | $536.00 | $670.00 | $48.70 – $584.43 | 25 |
| Infect ag genotype na hiv-1 revr trn/prt CPT 87901 | $1,070.40 | $1,338.00 | $257.45 – $1,168.82 | 25 |
| Infect ag na herpes simplex quant CPT 87530 | $178.40 | $223.00 | $32.13 – $194.49 | 21 |
| Infect ag na orthopoxvirus amp prb each CPT 87593 | $52.00 | $226.00 | $49.71 – $153.93 | 22 |
| Infectious agent antigen immunoassay ql/sq multi step clostridium difficile toxin CPT 87324 | $49.60 | $62.00 | $11.16 – $63.45 | 20 |
| Infectious agent antigen immunoassay ql/sq multi step cryptosporidium CPT 87328 | $57.60 | $72.00 | $12.96 – $71.69 | 20 |
| Infectious agent antigen immunoassay ql/sq multi step giardia CPT 87329 | $49.60 | $62.00 | $11.98 – $71.69 | 25 |
| Infectious agent antigen immunoassay ql/sq multi step helicobacter pylori stool CPT 87338 | $60.00 | $75.00 | $14.38 – $65.29 | 25 |
| Infectious agent antigen immunoassay ql/sq multi step hepatitis b surface agn CPT 87340 | $43.20 | $54.00 | $10.33 – $48.94 | 25 |
| Infectious agent antigen immunoassay ql/sq multi step hepatitis b surface agn neutralization CPT 87341 | $43.20 | $54.00 | $10.33 – $46.90 | 25 |
| Infectious agent antigen immunoassay ql/sq multi step hiv-1 antigen(s) hiv-1&2 antibodies CPT 87389 | $100.00 | $125.00 | $24.08 – $109.32 | 25 |
| Infectious agent antigen immunoassay ql/sq multi step legionella urine CPT 87449 | $49.60 | $62.00 | $11.16 – $68.15 | 20 |
| Infectious agent antigen immunoassay ql/sq multi step rotavirus CPT 87425 | $60.00 | $75.00 | $11.98 – $71.69 | 20 |
| Infectious agent antigen immunoassay ql/sq multi step shiga-like toxin CPT 87427 | $49.60 | $62.00 | $11.98 – $55.54 | 25 |
| Infectious agent nucleic acid amplified probe CPT 87798 | $145.60 | $182.00 | $28.99 – $159.31 | 25 |
| Infectious agent nucleic acid amplified probe chlamydia trachomatis CPT 87491 | $145.60 | $182.00 | $28.99 – $159.31 | 26 |
| Infectious agent nucleic acid amplified probe clostridium difficile toxin gene(s) CPT 87493 | $154.40 | $193.00 | $30.43 – $169.21 | 25 |
| Infectious agent nucleic acid amplified probe cns pathogen 12-25 targets CPT 87483 | $1,214.40 | $1,518.00 | $57.44 – $1,892.18 | 21 |
| Infectious agent nucleic acid amplified probe hsv-1 CPT 87529 | $145.60 | $182.00 | $32.76 – $159.31 | 20 |
| Infectious agent nucleic acid amplified probe methicillin resistant staphylococcus aureus CPT 87641 | $140.00 | $182.00 | $35.09 – $159.31 | 25 |
| Infectious agent nucleic acid amplified probe neisseria gonorrhoeae CPT 87591 | $145.60 | $182.00 | $28.99 – $171.18 | 26 |
| Infectious agent nucleic acid amplified probe sars-cov-2/covid-19 CPT 87635 | $100.00 | $192.00 | $44.36 – $232.95 | 25 |
| Infectious agent nucleic acid amplified probe sars-cov-2/inf a&b/rsv CPT 87637 | $100.00 | $447.00 | $82.21 – $647.54 | 25 |
| Infectious agent nucleic acid amplified probe streptococcus group a CPT 87651 | $122.40 | $153.00 | $28.99 – $159.31 | 25 |
| Infectious agent nucleic acid amplified probe trichomonas vaginalis CPT 87661 | $175.20 | $219.00 | $35.09 – $159.31 | 26 |
| Infectious agent nucleic acid amp probe mycobacterium tuberculosis rifampin resistance CPT 87564 | $307.20 | $384.00 | $57.58 – $230.31 | 19 |
| Infectious agent nucleic acid multiplex amplified probe gi pathogen 12-25 targets CPT 87507 | $515.20 | $644.00 | $65.31 – $1,892.18 | 20 |
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.