Financial Information

Financial Services

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.


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

Price Estimator Tool


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 10/1/2022:

CPT Code Technical Component Professional Component Total
Emergency Department
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 Femur 73552 $405.00 $405.00
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 Abdomen 76700 $893.00 $893.00
Ultrasound  Tranvaginal 76830 $835.00 $835.00
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
Lipid Panel 80061 $194.00 $194.00
Liver Function Profile 80076 $87.00 $87.00
Urinalysis 81001 $62.00 $62.00
Hemoglobin A1C 83036 $88.00 $88.00
Prostate Specific antigen (PSA) Total or Screening G0103/84153 $132.00 $132.00
Thyroid Stimulating Hormone 84443 $176.00 $176.00
Beta HCG – 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
Prothrombin Time 85610 $57.00 $57.00
Culture Urine 87086 $42.00 $42.00
Outpatient Procedure
Echocardiogram 93306 $2,450.00 $2,450.00
Colonoscopy Screening G0121 $5,560.00 $745.00 $6,305.00
Evaluation, PT & OT 97161 $344.00 $344.00
Evaluation, Speech 92521 $425.00 $425.00
Therapeutic Activities, PT & OT 97530 $159.00 $159.00

Accepted Insurances:

Anthem Commercial
Anthem Exchange
Anthem Medicare Advantage
Beacon Health (Behavioral Health only)
Cenpatico/Envolve Health Mgd Medicaid & AM Better Exchange Product (Behavioral Health Only)
HPHC Commercial
HPHC Elevate Health
HPHC Exchange
Medicare Advantage
Martin’s Point Healthcare
MVP Healthcare
NH Healthy Families -Mgd Medicaid
NH Healthy Families-Exchange-AM Better
Optum Health (Behavioral Health Only)
Tufts Health Plan
United Healthcare-Commercial
United Healthcare-Medicare Advantage
VT BCBS Commercial
The VT Health Plan

For questions, or more information, call (603) 388-4234.