Services Pricing

The following is a list of some common services/procedures performed at Upper Connecticut Valley Hospital. It is important to note that these are price estimates. There may be additional related procedures, tests, treatments or supplies may be provided and billed separately. Patients may call 603-388-4234 to discuss more specific billing rates and procedures.

Click here for access to the Hospital Chargemaster (this is a .xls document, enable popups)

The information provided is a comprehensive list of charges for each inpatient and outpatient service or item provided by a hospital, also known as a chargemaster, which Upper Connecticut Valley Hospital posts on an annual basis.

PLEASE NOTE: Standard charges shown in the chargemaster do not necessarily reflect what a patient ultimately pays for services and therefore may not be a helpful tool to estimate their out of pocket responsibility or to compare hospital costs.

Services rendered may include professional as well as facility charges, which will be listed separately in the chargemaster.

Because of the complexity of hospital billing, and because chargemaster rates are updated periodically, patients should contact our patient financial services staff at 603-388-4234 for information about the cost of your care.

For more information regarding Price Transparency & Healthcare Pricing click below:

Price Transparency

2019 Financial / HFMA Consumer Guide to Healthcare Pricing

Pricing

The following is a list of some common services/procedures performed at Upper Connecticut Valley Hospital.  It is important to note that these are price estimates.  There may be additional related procedures, tests, treatments or supplies may be provided and billed separately.   Patients may call 603-388-4234 to discuss more specific billing rates and procedures.
      As of 10/1/19
    CPT Code Technical Component Professional Component Total
           
Emergency Department        
  ED Room Level I 99281  $          220.00  $           44.00  $          264.00
  ED Room Level II 99282  $          404.00  $           86.00  $          490.00
  ED Room Level III 99283  $          703.00  $          128.00  $          831.00
  ED Room Level IV 99284  $       1,136.00  $          242.00  $       1,378.00
  ED Room Level V 99285  $       1,655.00  $          357.00  $       2,012.00
  ED Room Critical Care 1st hour 99291  $       2,332.00  $          459.00  $       2,791.00
  ED Room Critical Care each Additional 30 min 99292  $          651.00  $          231.00  $          882.00
           
           
Radiology          
           
  X-ray Chest 2 views 71046  $          301.00  $           25.00  $          326.00
  X-ray Neck & Spine 4 view 72050  $          762.00  $           33.00  $          795.00
  X-ray Lower Spine 72100  $          560.00  $           24.00  $          584.00
  X-ray Pelvis 1 or 2 view 72170  $          398.00  $           19.00  $          417.00
  X-ray Femur 73552  $          416.00  $           19.00  $          435.00
  X-ray Knee 1-2 Views 73560  $          333.00  $           18.00  $          351.00
  X-ray Knee 3 Views 73562      $                 -  
  X-ray Foot 2 views 73630  $          333.00  $           18.00  $          351.00
  X-ray Abdomen Complete 74019  $          557.00  $           28.00  $          585.00
  X-ray Esophagus 74220      $                 -  
           $                 -  
  CT Scan Head without Contrast 70450  $       1,189.00  $           98.00  $       1,287.00
  CT Maxillofacial W/O contrast 70486  $       1,676.00  $          132.00  $       1,808.00
  CT Scan Chest without Contrast 71250  $       1,722.00  $          122.00  $       1,844.00
  CT Chest with Contrast 71260  $       2,166.00  $          144.00  $       2,310.00
  CT Scan Pelvis without Contrast 72192  $       1,464.00  $          127.00  $       1,591.00
  CT scan Abdomen without Contrast 74150  $       1,447.00  $          140.00  $       1,587.00
  CT Abdomen Angiogram 74175  $       2,991.00  $          223.00  $       3,214.00
           
  MRI Angiography Head w/o Contrast 70544  $       3,142.00  $          125.00  $       3,267.00
  MRI Brain without Contrast 70551  $       1,576.00  $          155.00  $       1,731.00
  MRI Brain With and Without contrast 70553  $       2,644.00  $          238.00  $       2,882.00
  MRI Cervical Spine W/o Contrast 72141  $       1,533.00  $          155.00  $       1,688.00
  MRI Thoracic Spine W/o Contrast 72146  $       2,202.00  $          155.00  $       2,357.00
  MRI Lumbar Spine without Contrast 72148  $       1,510.00  $          155.00  $       1,665.00
  MRI Cervical Spine W and W/O Contrast 72156  $       2,670.00  $          238.00  $       2,908.00
  MRI Thoracic Spine with and W/o Contrast 72157  $       2,681.00  $          238.00  $       2,919.00
  MRI Lumbar Spine W and Without Contrast 72158  $       2,663.00  $          238.00  $       2,901.00
  MRI Pelvis with and W/O Contrast 72197  $       3,688.00  $          234.00  $       3,922.00
  MRI Lower Extremity with and W/O contrast  73720  $       3,719.00  $          223.00  $       3,942.00
  MRI Lower Extremity W/O contrast 73721  $       1,701.00  $          142.00  $       1,843.00
           
  Ultrasound Breast 76641  $          781.00  $           76.00  $          857.00
  Ultrasound Abdomen 76700  $       1,256.00  $           84.00  $       1,340.00
  Ultrasound  Tranvaginal 76830  $       1,302.00  $           73.00  $       1,375.00
  Ultrasound Carotid Duplex Scan Bilateral 93880  $       1,812.00  $           84.00  $       1,896.00
           
  Bone Density Study 77080  $          457.00  $           19.00  $          476.00
  Mammogrophy Digital Screening 77067  $          728.00  $           96.00  $          824.00
           
Laboratory        
  Venous Specimen Collection Fee 36415  $           22.00    $           22.00
  Basic Metabolic Panel 80048  $           63.00    $           63.00
  Lipid Panel 80061  $          112.00    $          112.00
  Liver Function Profile 80076  $           86.00    $           86.00
  Urinalysis 81001  $           45.00    $           45.00
  Hemoglobin A1C 83036  $           86.00    $           86.00
  Prostate Specific antigen (PSA) Total or Screening G0103/84153  $          132.00    $          132.00
  Thyroid Stimulating Hormone 84443  $          144.00    $          144.00
  Beta HCG - Pregnancy blood count 84702  $          132.00    $          132.00
  Compete Blood Count w WBC Count 85025  $           63.00    $           63.00
  Complete Blood Count with Differential 85027  $           59.00    $           59.00
  Prothrombin Time 85610  $           60.00    $           60.00
  Culture Urine 87086  $           66.00    $           66.00
           
Outpatient Procedure        
  Echocardiogram 93306  $       1,411.00    $       1,411.00
  Colonoscopy Screening G0121  $       5,260.00  $          709.00  $       5,969.00
           
Rehab          
  Evaluation, PT & OT 97161  $          372.00    $          372.00
  Evaluation, Speech 92521  $          523.00    $          523.00
  Therapeutic Activities, PT & OT 97530  $          176.00    $          176.00
  Treatment Modality, Supervised  PT & OT    $          176.00    $          176.00
  Treatment, Speech    $          369.00    $          369.00