Upper Connecticut Valley Hospital offers many financial assistance and referral programs to ensure that cost will not be a barrier to anyone in our community getting the healthcare services they need.
Upper Connecticut Valley Hospital (UCVH) provides eligible patients fully discounted emergency or medically necessary care through UCV Free Care. Certain exclusions apply, including, for example, elective services, balances covered by other funding sources, and failure to cooperate in securing alternative funding sources (including Medicaid, Medicare, Insurance exchange and Employer sponsored insurance). This document is only a summary. Please click here to review our Plain Language Summary or Financial Assistance Policy for complete details.
Assistance Offered and Eligibility
Patients who qualify for assistance receive 100% coverage through UCV Free Care for emergency and other medically necessary services. The necessity for medical treatment of any patient will be based on the clinical judgment of the health care provider without regard to the financial status of the patient. All patients will be treated for emergency medical conditions regardless of ability to pay or to qualify for financial assistance in accordance with federal and state law.
To be eligible for Financial Assistance, patients must qualify based on income as follows:
- Household annual income does not exceed 300% of the Federal Poverty guidelines, based upon family size.
Patients without insurance, and not eligible for UCV Free Care, will not be charged more than the amounts generally billed to patients who have insurance.
Applying for Financial Assistance
To expedite services, please print our Financial Application. If you need assistance completing your application you can schedule an appointment with our Patient Financial Coordinator by calling (603) 388-4234.
Once complete, you may drop off the application or send it in the mail to Patient Financial Services, 181 Corliss Lane, Colebrook, NH 03576. You can fax your application to 603-388-4171. You may also scan your completed document and return it electronically to Jodi Smith, [email protected].
There are services offered at Upper Connecticut Valley Hospital that may cause you to incur charges from other billing companies as the services are provided by non-participating providers. Please click here to view a list of Participating Provider and Non-Participating Providers.
For questions, or more information, call (603) 388-4234.
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.
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:
|CPT Code||Technical Component||Professional Component||Total|
|ED Room Level I||99281||$222.00||$76.00||$298.00|
|ED Room Level II||99282||$402.00||$130.00||$532.00|
|ED Room Level III||99283||$709.00||$135.00||$844.00|
|ED Room Level IV||99284||$1,115.00||$434.00||$1,549.00|
|ED Room Level V||99285||$1,600.00||$755.00||$2,355.00|
|ED Room Critical Care 1st hour||99291||$3,340.00||$726.00||$4,066.00|
|ED Room Critical Care each Additional 30 min||99292||$745.00||$207.00||$952.00|
|X-ray Chest 2 views||71046||$337.00||Professional component to be charged by Coos North Country Radiology||$337.00|
|X-ray Neck & Spine 4 view||72050||$509.00||$509.00|
|X-ray Lower Spine||72100||$411.00||$411.00|
|X-ray Pelvis 1 or 2 view||72170||$399.00||$399.00|
|X-ray Knee 1-2 Views||73560||$393.00||$393.00|
|X-ray Knee 3 Views||73562||$454.00||$454.00|
|X-ray Foot 2 views||73630||$362.00||$362.00|
|X-ray Abdomen Complete||74019||$374.00||$374.00|
|CT Scan Head without Contrast||70450||$2,085.00||Professional component to be charged by Coos North Country Radiology||$2,085.00|
|CT Maxillofacial W/O contrast||70486||$2,085.00||$2,085.00|
|CT Scan Chest without Contrast||71250||$2,085.00||$2,085.00|
|CT Chest with Contrast||71260||$2,360.00||$2,360.00|
|CT Scan Pelvis without Contrast||72192||$2,085.00||$2,085.00|
|CT scan Abdomen without Contrast||74150||$2,085.00||$2,085.00|
|CT Abdomen Angiogram||74175||$3,559.00||$3,559.00|
|MRI Angiography Head w/o Contrast||70544||$3,127.00||Professional component to be charged by Coos North Country Radiology||$3,127.00|
|MRI Brain without Contrast||70551||$3,635.00||$3,635.00|
|MRI Brain With and Without contrast||70553||$5,404.00||$5,404.00|
|MRI Cervical Spine W/o Contrast||72141||$3,902.00||$3,902.00|
|MRI Thoracic Spine W/o Contrast||72146||$3,902.00||$3,902.00|
|MRI Lumbar Spine without Contrast||72148||$3,902.00||$3,902.00|
|MRI Cervical Spine W and W/O Contrast||72156||$4,919.00||$4,919.00|
|MRI Thoracic Spine with and W/o Contrast||72157||$4,919.00||$4,919.00|
|MRI Lumbar Spine W and Without Contrast||72158||$5,248.00||$5,248.00|
|MRI Pelvis with and W/O Contrast||72197||$4,869.00||$4,869.00|
|MRI Lower Extremity with and W/O contrast||73720||$5,469.00||$5,469.00|
|MRI Lower Extremity W/O contrast||73721||$3,281.00||$3,281.00|
|Ultrasound Breast||76641||$772.00||Professional component to be charged by Coos North Country Radiology||$772.00|
|Ultrasound Carotid Duplex Scan Bilateral||93880||$1,254.00||$1,254.00|
|Bone Density Study||77080||$668.00||$668.00|
|Mammogrophy Digital Screening||77067||$942.00||$942.00|
|Venous Specimen Collection Fee||36415||$23.00||$23.00|
|Basic Metabolic Panel||80048||$77.00||$77.00|
|Liver Function Profile||80076||$87.00||$87.00|
|Prostate Specific antigen (PSA) Total or Screening||G0103/84153||$132.00||$132.00|
|Thyroid Stimulating Hormone||84443||$176.00||$176.00|
|Beta HCG â€“ Pregnancy blood count||84702||$78.00||$78.00|
|Compete Blood Count w WBC Count||85025||$67.00||$67.00|
|Complete Blood Count with Differential||85027||$65.00||$65.00|
|Evaluation, PT & OT||97161||$344.00||$344.00|
|Therapeutic Activities, PT & OT||97530||$159.00||$159.00|
For questions, or more information, call (603) 388-4234.