Mt. Ascutney Hospital and Health Center

Consumer-Friendly Price List for Hospital Services. Posted and Effective as of 11-4-2021.

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Service DescriptionService CodeCash PriceRates
Service DescriptionService CodeCash PriceRates
CT Scan
CT scanCPT 70450$1,710
CT scan of abdomen and pelvis with contrastCPT 74177$3,160
CT scan of pelvis with contrastCPT 72193$2,986
Cancer Services
Chemo iv infusion 1 hrCPT 96413$173
Chemo iv infusion addl hrCPT 96415$112
Irrig drug delivery deviceCPT 96523$22
Clinic
Amputation of toeCPT 28820$1,586
Application of paste bootCPT 29580$290
Biopsy/removal lymph nodesCPT 38500$1,141
Cmptr ophth img optic nerveCPT 92133$86
Colon ca scrn not hi rsk indHCPCS G0121$983
Colonoscopy w/lesion removalCPT 45384$1,155
Colorectal scrn; hi risk indHCPCS G0105$983
Comp multidisipln evaluationHCPCS H2000$146
Correction hallux valgusCPT 28296$2,464
Corrj halux rigdus w/o impltCPT 28289$2,525
Deb subq tissue 20 sq cm/<CPT 11042$612
Debride nail 1-5CPT 11720$198
Debride nail 6 or moreCPT 11721$143
Destruct b9 lesion 1-14CPT 17110$199
Determine refractive stateCPT 92015$62
Developmental screen w/scoreCPT 96110$27
Diab manage trn per indivHCPCS G0108$86
Drain/inj joint/bursa w/o usCPT 20610$285
Drainage of skin abscessCPT 10061$486
Drainage of skin abscessCPT 10060$285
Echo exam of eyeCPT 76519$323
Echo exam of eye thicknessCPT 76514$28
Exc f/e/e/n/l mal+mrg 1.1-2CPT 11642$566
Exc face-mm b9+marg 1.1-2 cmCPT 11442$437
Exc h-f-nk-sp b9+marg 2.1-3CPT 11423$610
Exc s/n/h/f/g mal+mrg 3.1-4CPT 11624$727
Exc shoulder tum deep 5 cm/>CPT 23073$682
Exc tr-ext b9+marg 0.6-1 cmCPT 11401$327
Exc tr-ext b9+marg 1.1-2 cmCPT 11402$392
Exc tr-ext b9+marg 2.1-3cmCPT 11403$502
Exc tr-ext b9+marg >4.0 cmCPT 11406$1,094
Exc tr-ext mal+marg 3.1-4 cmCPT 11604$648
Exc tr-ext mal+marg >4 cmCPT 11606$953
Eye exam establish patientCPT 92012$146
Eye exam new patientCPT 92004$261
Eye exam&tx estab pt 1/>vstCPT 92014$234
Fusion of big toe jointCPT 28750$4,309
Hospital discharge dayCPT 99239$298
Hospital discharge dayCPT 99238$216
Incision of foot fasciaCPT 28008$1,759
Init pm e/m new pat infantCPT 99381$224
Initial hospital careCPT 99222$388
Initial hospital careCPT 99223$468
Initial hospital careCPT 99221$282
Initial new patient preventative medicine evaluation (18-3...CPT 99385$277
Initial new patient preventative medicine evaluation (40-6...CPT 99386$315
Initial observation careCPT 99219$392
Inject trigger points 3/>CPT 20553$683
Insert tunneled cv cathCPT 36561$1,659
Intmd rpr s/a/t/ext 2.6-7.5CPT 12032$538
Lap ing hernia repair initCPT 49650$1,898
Lap ing hernia repair recurCPT 49651$2,186
Laparo cholecystectomy/graphCPT 47563$2,808
Laparoscopy appendectomyCPT 44970$2,669
Laparoscopy fundoplastyCPT 43280$4,238
Mast simple completeCPT 19303$4,422
Medical services after hrsCPT 99050$64
New patient office or other outpatient visit, 30 minCPT 99203$215
New patient office or other outpatient visit, 45 minCPT 99204$330
New patient office or other outpatient visit, 60 minCPT 99205$407
Nursing fac care subseqCPT 99309$150
Nursing fac care subseqCPT 99308$107
Nursing fac care subseqCPT 99307$64
Nursing fac care subseqCPT 99310$187
Nursing fac discharge dayCPT 99316$258
Nursing facility care initCPT 99305$162
Nursing facility care initCPT 99306$201
Nursing facility care initCPT 99304$122
Observation care dischargeCPT 99217$216
Office consultationCPT 99242$285
Office o/p est hi 40-54 minCPT 99215$305
Office o/p est low 20-29 minCPT 99213$127
Office o/p est minimal probCPT 99211$64
Office o/p est mod 30-39 minCPT 99214$200
Office o/p est sf 10-19 minCPT 99212$95
Office o/p new sf 15-29 minCPT 99202$156
Partial amputation of toeCPT 28825$1,851
Partial mastectomyCPT 19301$2,861
Partial removal foot fasciaCPT 28060$3,174
Partial removal of foot boneCPT 28122$3,122
Patient office consultation, 40 minCPT 99243$358
Patient office consultation, 60 minCPT 99244$440
Per pm reeval est pat 65+ yrCPT 99397$291
Per pm reeval est pat infantCPT 99391$170
Ppps, subseq visitHCPCS G0439$582
Prev visit est age 1-4CPT 99392$191
Prev visit est age 12-17CPT 99394$207
Prev visit est age 18-39CPT 99395$234
Prev visit est age 40-64CPT 99396$293
Prev visit est age 5-11CPT 99393$188
Psych diagnostic evaluationCPT 90791$337
Pure tone hearing test airCPT 92551$66
Removal of nail bedCPT 11750$509
Removal tunneled cv cathCPT 36590$950
Remove impacted ear wax uniCPT 69209$181
Remove int/ext hem 1 groupCPT 46255$1,564
Remove pilonidal cyst extenCPT 11771$1,283
Repair of hammertoeCPT 28285$1,502
Rmvl devital tis 20 cm/<CPT 97597$437
Rpr s/n/ax/gen/trnk 2.5cm/<CPT 12001$327
Rpr s/n/ax/gen/trnk2.6-7.5cmCPT 12002$353
Rpr umbil hern block > 5 yrCPT 49587$1,497
Rpr umbil hern reduc > 5 yrCPT 49585$1,970
Special eye evaluationCPT 92020$78
Subsequent hospital careCPT 99232$212
Subsequent hospital careCPT 99231$142
Subsequent hospital careCPT 99233$318
Trim nail(s) any numberCPT 11719$53
Trim skin lesionCPT 11055$95
Trim skin lesions 2 to 4CPT 11056$175
Visual acuity screenCPT 99173$42
Visual field examination(s)CPT 92083$170
Work related disability examCPT 99455$383
Xcapsl ctrc rmvl cplx wo ecpCPT 66982$4,142
EEG
Sleep study (Not Offered)CPT 95810--
EKG
Ecg record/reviewCPT 93268$379
Electrocardiogram tracingCPT 93005$290
Electrocardiogram, routine, with interpretation and reportCPT 93000$289
Emergency Room
Emergency dept visitCPT 99283$426
Emergency dept visitCPT 99284$680
Emergency dept visitCPT 99285$1,091
Emergency dept visitCPT 99282$287
Emergency dept visitCPT 99281$258
Hydrate iv infusion add-onCPT 96361$126
Hydration iv infusion initCPT 96360$145
Ther/proph/diag inj iv pushCPT 96374$111
Ther/proph/diag inj sc/imCPT 96372$38
Ther/proph/diag iv inf addonCPT 96366$124
Ther/proph/diag iv inf initCPT 96365$118
Tx/pro/dx inj new drug addonCPT 96375$56
Tx/pro/dx inj same drug adonCPT 96376$54
Tx/proph/dg addl seq iv infCPT 96367$56
Imaging
Abdomial ultrasound of pregnant uterus (Not Offered)CPT 76805--
Breast tomosynthesis biCPT 77063$126
Breast tomosynthesis uniCPT 77061$126
Mammography of both breastsCPT 77066$537
Mammography of one breastCPT 77065$537
Mammography, screening, bilateralCPT 77067$537
Ultrasound breast limitedCPT 76642$714
Ultrasound of abdomenCPT 76700$957
Ultrasound pelvis through vaginaCPT 76830$866
Inpatient Procedures
Cardiac valve or cardiothoracic procedure with cardiac cat... (Not Offered)DRG 216--
Cervical spinal fusion without CC or MCC (Not Offered)DRG 473--
Major joint replacement or reattachment of lower extremity... (Not Offered)DRG 470--
Spinal fusion except cervical without MCC (Not Offered)DRG 460--
Uterine and adnexa procedures for non-malignancy without C... (Not Offered)DRG 743--
Laboratory
Acetone assayCPT 82010$121
Agent nos assay w/opticCPT 87899$288
Alpha-fetoprotein serumCPT 82105$211
Antinuclear antibodiesCPT 86038$167
Assay glucose blood quantCPT 82947$53
Assay iga/igd/igg/igm eachCPT 82784$111
Assay of blood lipoproteinCPT 83721$118
Assay of blood/uric acidCPT 84550$67
Assay of ck (cpk)CPT 82550$94
Assay of creatinineCPT 82565$67
Assay of ferritinCPT 82728$189
Assay of folic acid serumCPT 82746$202
Assay of free thyroxineCPT 84439$130
Assay of gonadotropin (fsh)CPT 83001$278
Assay of ironCPT 83540$98
Assay of lactic acidCPT 83605$159
Assay of leadCPT 83655$180
Assay of lipaseCPT 83690$69
Assay of magnesiumCPT 83735$98
Assay of natriuretic peptideCPT 83880$505
Assay of parathormoneCPT 83970$502
Assay of phosphorusCPT 84100$70
Assay of serum potassiumCPT 84132$68
Assay of total thyroxineCPT 84436$80
Assay of urea nitrogenCPT 84520$51
Assay test for blood fecalCPT 82274$157
Basic metabolic panelCPT 80048$126
Blood culture for bacteriaCPT 87040$114
Blood gases any combinationCPT 82803$266
Blood test, clotting timeCPT 85610$59
Blood test, comprehensive group of blood chemicalsCPT 80053$147
Blood test, lipidsCPT 80061$139
Blood test, thyroid stimulating hormone (TSH)CPT 84443$205
C-reactive proteinCPT 86140$51
C-reactive protein hsCPT 86141$154
Ccp antibodyCPT 86200$178
Chorionic gonadotropin assayCPT 84703$100
Chorionic gonadotropin testCPT 84702$176
Chylmd trach dna amp probeCPT 87491$304
Coagulation assessment blood testCPT 85730$86
Complete blood cell count (CBC), automatedCPT 85027$84
Complete blood cell count (CBC), with differential white b...CPT 85025$102
Cryptosporidium ag iaCPT 87328$165
Cultr bacteria except bloodCPT 87075$137
Culture othr specimn aerobicCPT 87070$129
Culture type immunologicCPT 87147$78
Cytopath c/v thin layerCPT 88142$301
Detect agent nos dna ampCPT 87798$304
Dna/rna amplified probeCPT 87150$304
Drug test prsmv chem anlyzrCPT 80307$331
Drug test prsmv dir opt obsCPT 80305$34
Epstein-barr nuclear antigenCPT 86664$206
Feces culture aerobic bactCPT 87045$111
Fibrin degradation quantCPT 85379$140
Free assay (ft-3)CPT 84481$206
Giardia ag iaCPT 87329$169
Glycosylated hemoglobin testCPT 83036$140
HematocritCPT 85014$36
HemoglobinCPT 85018$35
Hep b core antibody totalCPT 86704$180
Hep b surface antibodyCPT 86706$154
Hepatitis a antibodyCPT 86708$183
Hepatitis b surface ag iaCPT 87340$154
Hepatitis c ab testCPT 86803$158
Hepatitis c revrs trnscrpjCPT 87522$635
Heterophile antibody screenCPT 86308$151
Hiv-1/hiv-2 1 result antbdyCPT 86703$158
Hla ii typing 1 locus lrCPT 81376$415
Hpv high-risk typesCPT 87624$237
Immunoassay nonantibodyCPT 83516$170
Immunofix e-phoresis serumCPT 86334$322
Immunohisto antb 1st stainCPT 88342$690
Influenza dna amp probeCPT 87502$657
Iron binding testCPT 83550$127
Kidney function panel testCPT 80069$106
Lactate (ld) (ldh) enzymeCPT 83615$87
Liver function blood testCPT 80076$118
Lyme disease antibodyCPT 86618$185
Lyme disease antibodyCPT 86617$222
Microbe susceptible micCPT 87186$155
Microscopic exam of urineCPT 81015$43
Mumps antibodyCPT 86735$195
N.gonorrhoeae dna amp probCPT 87591$381
Obstetric blood test panel (Not Offered)CPT 80055--
Organic acid single quantCPT 83921$269
Particle agglut antbdy scrnCPT 86403$118
Protein e-phoresis serumCPT 84165$137
Rbc antibody screenCPT 86850$157
Rbc sed rate nonautomatedCPT 85651$51
Resp virus 3-5 targetsCPT 87631$314
Reticyte/hgb concentrateCPT 85046$66
Rheumatoid factor quantCPT 86431$85
Routine venipunctureCPT 36415$30
Rubella antibodyCPT 86762$198
Rubeola antibodyCPT 86765$184
Smear gram stainCPT 87205$65
Stool cultr aerobic bact eaCPT 87046$118
Strep a dna amp probeCPT 87651$304
Tb test cell immun measureCPT 86480$673
Tissue exam by pathologistCPT 88305$766
Tissue exam by pathologistCPT 88304$567
Total prostate-specific antigen (PSA) testCPT 84153$226
Total prostate-specific antigen (PSA) testCPT 84154$273
Ur albumin quantitativeCPT 82043$70
Urinalysis testCPT 81003$37
Urinalysis testCPT 81002$18
Urinalysis test using microscopeCPT 81001$46
Urinalysis test using microscope (Not Offered)CPT 81000--
Urine culture/colony countCPT 87086$68
Urine pregnancy testCPT 81025$92
Varicella-zoster antibodyCPT 86787$191
Vitamin b-12CPT 82607$155
Vitamin d 25 hydroxyCPT 82306$243
MRI
MRI ScanCPT 70553$6,767
MRI scan of leg jointCPT 73721$4,775
MRI scan of lower spinal canalCPT 72148$4,378
Other Diagnostic
Extracranial bilat studyCPT 93880$731
Home sleep test/type 3 portaHCPCS G0399$520
Musc test done w/n test compCPT 95886$736
Musc tst done w/nerv tst limCPT 95885$522
Nrv cndj test 7-8 studiesCPT 95910$885
Nrv cndj test 9-10 studiesCPT 95911$1,194
Nrv cndj tst 5-6 studiesCPT 95909$742
Slp stdy unattendedCPT 95800$199
Vascular studyCPT 93976$747
Other Therapeutic
Blood transfusion serviceCPT 36430$564
Cardiac rehab/monitorCPT 93798$286
PhlebotomyCPT 99195$146
Pulmonary rehab w exerHCPCS G0424$175
Rbc leukocytes reducedHCPCS P9016$555
Pharmacy
Ct abd & pelvis w/o contrastCPT 74176$1,657
Ct angiography chestCPT 71275$7,860
Ct neck spine w/o dyeCPT 72125$2,544
Ct thorax dx c-CPT 71250$2,524
Culture aerobic identifyCPT 87077$117
Dxa bone density axialCPT 77080$687
Echo exam of abdomenCPT 76705$740
Extremity studyCPT 93971$588
Mri brain stem w/o dyeCPT 70551$4,944
Tte w/doppler completeCPT 93306$1,547
Us exam of head and neckCPT 76536$862
X-ray exam abdomen 1 viewCPT 74018$334
X-ray exam chest 1 viewCPT 71045$306
X-ray exam chest 2 viewsCPT 71046$417
X-ray exam complete abdomenCPT 74022$679
X-ray exam l-s spine 2/3 vwsCPT 72100$600
X-ray exam of finger(s)CPT 73140$507
X-ray exam of shoulderCPT 73030$430
X-ray exam thorac spine 2vwsCPT 72070$474
Psychiatric
Family psychotherapy, including patient, 50 min (Not Offered)CPT 90847--
Family psychotherapy, not including patient, 50 minCPT 90846$270
Group psychotherapy (Not Offered)CPT 90853--
Psychotherapy, 30 minCPT 90832$168
Psychotherapy, 45 minCPT 90834$222
Psychotherapy, 60 minCPT 90837$335
Pulmonary Function
Co/membane diffuse capacityCPT 94729$259
Evaluation of wheezingCPT 94060$618
Pulm funct tst plethysmograpCPT 94726$334
Radiology
X-Ray of lower backCPT 72110$822
X-ray exam hip uni 2-3 viewsCPT 73502$882
X-ray exam neck spine 4/5vwsCPT 72050$768
X-ray exam of ankleCPT 73610$496
X-ray exam of footCPT 73630$482
X-ray exam of handCPT 73130$489
X-ray exam of knee 1 or 2CPT 73560$439
X-ray exam of knee 3CPT 73562$550
X-rays at surgery add-onCPT 74301$479
Respiratory
Airway inhalation treatmentCPT 94640$302
Surgical Procedures
Biopsy exam of esophagus, stomach or small bowel using an ...CPT 43239$6,934
Biopsy exam of large bowel using an endoscopeCPT 45380$7,471
Biopsy of prostate glandCPT 55700$3,877
Diagnostic exam of esophagus, stomach or small bowel using...CPT 43235$3,989
Diagnostic exam of large bowel using an endoscopeCPT 45378$5,266
Injection(s) of anesthetic into lower spine using imaging ...CPT 64483$2,439
Injection(s) of therapeutic substanceCPT 62323$2,654
Injection(s) of therapeutic substance (Not Offered)CPT 62322--
Insertion of catheter into left heart for diagnosis (Not Offered)CPT 93452--
Obstetric care, planned cesarean delivery (Not Offered)CPT 59510--
Obstetric care, planned vaginal delivery (Not Offered)CPT 59400--
Obstetric care, planned vaginal delivery (post delivery by... (Not Offered)CPT 59610--
Removal of cataract with insertion of lensCPT 66984$14,112
Removal of gallbladder using an endoscopeCPT 47562$25,916
Removal of one knee cartilage using an endoscope (Not Offered)CPT 29881--
Removal of one or more breast growth, open procedureCPT 19120$1,042
Removal of polyps or growths of large bowel using an endos...CPT 45385$7,100
Removal of recurring cataract in lens capsule using laserCPT 66821$4,766
Removal of tonsils and adenoid glands, patient younger tha... (Not Offered)CPT 42820--
Repair of groin hernia patient age 5 years or olderCPT 49505$21,296
Shaving of shoulder bone using endoscope (Not Offered)CPT 29826--
Surgical removal of prostate and surrounding lymph nodes u... (Not Offered)CPT 55866--
Ultrasound examination of lower large bowel using an endos... (Not Offered)CPT 45391--
Therapy
Aquatic therapy/exercisesCPT 97113$218
Gait training therapyCPT 97116$142
Manual therapy 1/> regionsCPT 97140$149
Neuromuscular reeducationCPT 97112$167
Ot eval low complex 30 minCPT 97165$300
Ot eval mod complex 45 minCPT 97166$364
Physical therapy, therapeutic exerciseCPT 97110$160
Pt eval low complex 20 minCPT 97161$300
Pt eval mod complex 30 minCPT 97162$364
Self care mngment trainingCPT 97535$174
Therapeutic activitiesCPT 97530$174
Ultrasound therapyCPT 97035$64
Wheelchair mngment trainingCPT 97542$152
Uncategorized
Admin influenza virus vacHCPCS G0008$74
Admin pneumococcal vaccineHCPCS G0009$37
Immunotherapy injectionsCPT 95117$133