Prices Posted and Effective on 12-31-2020

Mt. Ascutney Hospital and Health Center - Price List for Shoppable Services

Prices Posted and Effective as of 12-31-2020

Disclaimer: The Hospital determines its standard charges for patient items and services through the use of a chargemaster system, which is a list of charges for the components of patient care that go into every patient’s bill. These are the baseline rates for items and services provided at the Hospital. The chargemaster is similar in concept to the manufacturer’s suggested retail price (“MSRP”) on a particular product or good. The charges listed provide only a general starting point in determining the potential costs of an individual patient’s care at the Hospital. This list does not reflect the actual out-of-pocket costs that may be paid by a patient for any particular service, it is not binding, and the actual charges for items and services may vary. Individuals with questions about their out-of-pocket costs of service and other financial information should contact the hospital or consider contacting their insurers for further information. The cost of treatment also may be impacted by variables involved in a patient’s actual care, such as specific equipment or supplies required, the length of time spent in surgery or recovery, additional tests, or any changes in care or unexpected conditions or complications that arise. Lab charges may vary depending on quantity of specimens analyzed and the location of the lab test analysis.
Service DescriptionService CodeCash PriceRates
Service DescriptionService CodeCash PriceRates
CT Scan
CT scanCPT 70450$1,668
CT scan of abdomen and pelvis with contrastCPT 74177$3,572
CT scan of pelvis with contrastCPT 72193$2,277
Ct abd & pelvis w/o contrastCPT 74176$3,414
Ct angiography chestCPT 71275$3,572
Ct neck spine w/o dyeCPT 72125$1,962
Ct thorax dx c-CPT 71250$2,119
Cancer Services
Chemo iv infusion 1 hrCPT 96413$169
Chemo iv infusion addl hrCPT 96415$110
Irrig drug delivery deviceCPT 96523$22
Tte w/doppler completeCPT 93306$1,510
Amputation of toeCPT 28820$1,547
Application of paste bootCPT 29580$202
Biopsy/removal lymph nodesCPT 38500$1,113
Cmptr ophth img optic nerveCPT 92133$83
Colon ca scrn not hi rsk indHCPCS G0121$959
Colonoscopy w/lesion removalCPT 45384$1,127
Colorectal scrn; hi risk indHCPCS G0105$959
Comp multidisipln evaluationHCPCS H2000$142
Correction hallux valgusCPT 28296$2,404
Corrj halux rigdus w/o impltCPT 28289$2,463
Deb subq tissue 20 sq cm/<CPT 11042$597
Debride nail 1-5CPT 11720$193
Debride nail 6 or moreCPT 11721$140
Destruct b9 lesion 1-14CPT 17110$194
Determine refractive stateCPT 92015$61
Developmental screen w/scoreCPT 96110$26
Diab manage trn per indivHCPCS G0108$83
Drain/inj joint/bursa w/o usCPT 20610$278
Drainage of skin abscessCPT 10061$474
Drainage of skin abscessCPT 10060$278
Echo exam of eyeCPT 76519$317
Echo exam of eye thicknessCPT 76514$27
Exc f/e/e/n/l mal+mrg 1.1-2CPT 11642$552
Exc face-mm b9+marg 1.1-2 cmCPT 11442$426
Exc h-f-nk-sp b9+marg 2.1-3CPT 11423$594
Exc s/n/h/f/g mal+mrg 3.1-4CPT 11624$710
Exc shoulder tum deep 5 cm/>CPT 23073$666
Exc tr-ext b9+marg 0.6-1 cmCPT 11401$319
Exc tr-ext b9+marg 1.1-2 cmCPT 11402$382
Exc tr-ext b9+marg 2.1-3cmCPT 11403$490
Exc tr-ext b9+marg >4.0 cmCPT 11406$1,068
Exc tr-ext mal+marg 3.1-4 cmCPT 11604$632
Exc tr-ext mal+marg >4 cmCPT 11606$930
Eye exam establish patientCPT 92012$142
Eye exam new patientCPT 92004$254
Eye exam&tx estab pt 1/>vstCPT 92014$229
Fusion of big toe jointCPT 28750$4,204
Hospital discharge dayCPT 99239$290
Hospital discharge dayCPT 99238$210
Immunotherapy injectionsCPT 95117$65
Incision of foot fasciaCPT 28008$1,716
Init pm e/m new pat infantCPT 99381$218
Initial hospital careCPT 99222$378
Initial hospital careCPT 99223$457
Initial hospital careCPT 99221$275
Initial new patient preventative medicine evaluation (18-3...CPT 99385$270
Initial new patient preventative medicine evaluation (40-6...CPT 99386$307
Initial observation careCPT 99219$382
Inject trigger points 3/>CPT 20553$666
Insert tunneled cv cathCPT 36561$1,618
Intmd rpr s/a/t/ext 2.6-7.5CPT 12032$525
Lap ing hernia repair initCPT 49650$1,852
Lap ing hernia repair recurCPT 49651$2,133
Laparo cholecystectomy/graphCPT 47563$2,739
Laparoscopy appendectomyCPT 44970$2,604
Laparoscopy fundoplastyCPT 43280$4,135
Mast simple completeCPT 19303$4,314
Medical services after hrsCPT 99050$62
New patient office or other outpatient visit, 30 minCPT 99203$210
New patient office or other outpatient visit, 45 minCPT 99204$322
New patient office or other outpatient visit, 60 minCPT 99205$398
Nursing fac care subseqCPT 99309$146
Nursing fac care subseqCPT 99308$105
Nursing fac care subseqCPT 99307$62
Nursing fac care subseqCPT 99310$182
Nursing fac discharge dayCPT 99316$252
Nursing facility care initCPT 99305$158
Nursing facility care initCPT 99306$196
Nursing facility care initCPT 99304$119
Observation care dischargeCPT 99217$210
Office consultationCPT 99242$278
Office o/p est hi 40-54 minCPT 99215$298
Office o/p est low 20-29 minCPT 99213$124
Office o/p est minimal probCPT 99211$62
Office o/p est mod 30-39 minCPT 99214$195
Office o/p est sf 10-19 minCPT 99212$93
Office o/p new sf 15-29 minCPT 99202$152
Partial amputation of toeCPT 28825$1,806
Partial mastectomyCPT 19301$2,791
Partial removal foot fasciaCPT 28060$3,097
Partial removal of foot boneCPT 28122$3,046
Patient office consultation, 40 minCPT 99243$350
Patient office consultation, 60 minCPT 99244$430
Per pm reeval est pat 65+ yrCPT 99397$284
Per pm reeval est pat infantCPT 99391$166
Ppps, subseq visitHCPCS G0439$284
Prev visit est age 1-4CPT 99392$186
Prev visit est age 12-17CPT 99394$202
Prev visit est age 18-39CPT 99395$229
Prev visit est age 40-64CPT 99396$286
Prev visit est age 5-11CPT 99393$183
Psych diagnostic evaluationCPT 90791$329
Pure tone hearing test airCPT 92551$65
Removal of nail bedCPT 11750$496
Removal tunneled cv cathCPT 36590$927
Remove impacted ear wax uniCPT 69209$176
Remove int/ext hem 1 groupCPT 46255$1,526
Remove pilonidal cyst extenCPT 11771$1,252
Repair of hammertoeCPT 28285$1,466
Rmvl devital tis 20 cm/<CPT 97597$426
Rpr s/n/ax/gen/trnk 2.5cm/<CPT 12001$319
Rpr s/n/ax/gen/trnk2.6-7.5cmCPT 12002$344
Rpr umbil hern block > 5 yrCPT 49587$1,460
Rpr umbil hern reduc > 5 yrCPT 49585$1,922
Special eye evaluationCPT 92020$76
Subsequent hospital careCPT 99232$207
Subsequent hospital careCPT 99231$138
Subsequent hospital careCPT 99233$310
Trim nail(s) any numberCPT 11719$51
Trim skin lesionCPT 11055$93
Trim skin lesions 2 to 4CPT 11056$171
Visual acuity screenCPT 99173$42
Visual field examination(s)CPT 92083$166
Work related disability examCPT 99455$374
Xcapsl ctrc rmvl cplx wo ecpCPT 66982$4,041
Sleep study (Not Offered)CPT 95810--
Ecg record/reviewCPT 93268$370
Electrocardiogram tracingCPT 93005$283
Electrocardiogram, routine, with interpretation and reportCPT 93000$289
Emergency Room
Emergency dept visitCPT 99283$415
Emergency dept visitCPT 99284$663
Emergency dept visitCPT 99285$1,065
Emergency dept visitCPT 99282$280
Emergency dept visitCPT 99281$251
Hydrate iv infusion add-onCPT 96361$123
Hydration iv infusion initCPT 96360$142
Ther/proph/diag inj iv pushCPT 96374$109
Ther/proph/diag inj sc/imCPT 96372$37
Ther/proph/diag iv inf addonCPT 96366$121
Ther/proph/diag iv inf initCPT 96365$114
Tx/pro/dx inj new drug addonCPT 96375$54
Tx/pro/dx inj same drug adonCPT 96376$53
Tx/proph/dg addl seq iv infCPT 96367$54
Abdomial ultrasound of pregnant uterus (Not Offered)CPT 76805--
Breast tomosynthesis biCPT 77063$123
Breast tomosynthesis uniCPT 77061$123
Echo exam of abdomenCPT 76705$722
Mammography of both breastsCPT 77066$524
Mammography of one breastCPT 77065$524
Mammography, screening, bilateralCPT 77067$524
Ultrasound breast limitedCPT 76642$697
Ultrasound of abdomenCPT 76700$934
Ultrasound pelvis through vaginaCPT 76830$845
Us exam of head and neckCPT 76536$842
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--
Acetone assayCPT 82010$118
Agent nos assay w/opticCPT 87899$281
Alpha-fetoprotein serumCPT 82105$206
Antinuclear antibodiesCPT 86038$176
Assay glucose blood quantCPT 82947$52
Assay iga/igd/igg/igm eachCPT 82784$108
Assay of blood lipoproteinCPT 83721$115
Assay of blood/uric acidCPT 84550$66
Assay of ck (cpk)CPT 82550$95
Assay of creatinineCPT 82565$66
Assay of ferritinCPT 82728$185
Assay of folic acid serumCPT 82746$198
Assay of free thyroxineCPT 84439$133
Assay of gonadotropin (fsh)CPT 83001$271
Assay of ironCPT 83540$95
Assay of lactic acidCPT 83605$155
Assay of leadCPT 83655$176
Assay of lipaseCPT 83690$67
Assay of magnesiumCPT 83735$98
Assay of natriuretic peptideCPT 83880$492
Assay of parathormoneCPT 83970$490
Assay of phosphorusCPT 84100$67
Assay of serum potassiumCPT 84132$66
Assay of total thyroxineCPT 84436$78
Assay of urea nitrogenCPT 84520$50
Assay test for blood fecalCPT 82274$153
Basic metabolic panelCPT 80048$123
Blood culture for bacteriaCPT 87040$110
Blood gases any combinationCPT 82803$259
Blood test, clotting timeCPT 85610$60
Blood test, comprehensive group of blood chemicalsCPT 80053$143
Blood test, lipidsCPT 80061$136
Blood test, thyroid stimulating hormone (TSH)CPT 84443$200
C-reactive proteinCPT 86140$50
C-reactive protein hsCPT 86141$150
Ccp antibodyCPT 86200$174
Chorionic gonadotropin assayCPT 84703$98
Chorionic gonadotropin testCPT 84702$202
Chylmd trach dna amp probeCPT 87491$297
Coagulation assessment blood testCPT 85730$86
Complete blood cell count (CBC), automatedCPT 85027$82
Complete blood cell count (CBC), with differential white b...CPT 85025$100
Cryptosporidium ag iaCPT 87328$165
Cultr bacteria except bloodCPT 87075$138
Culture aerobic identifyCPT 87077$114
Culture othr specimn aerobicCPT 87070$126
Culture type immunologicCPT 87147$77
Cytopath c/v thin layerCPT 88142$294
Detect agent nos dna ampCPT 87798$378
Dna/rna amplified probeCPT 87150$297
Drug test prsmv chem anlyzrCPT 80307$323
Drug test prsmv dir opt obsCPT 80305$33
Epstein-barr nuclear antigenCPT 86664$201
Feces culture aerobic bactCPT 87045$108
Fibrin degradation quantCPT 85379$147
Free assay (ft-3)CPT 84481$202
Giardia ag iaCPT 87329$164
Glycosylated hemoglobin testCPT 83036$142
HematocritCPT 85014$35
HemoglobinCPT 85018$35
Hep b core antibody totalCPT 86704$176
Hep b surface antibodyCPT 86706$150
Hepatitis a antibodyCPT 86708$179
Hepatitis b surface ag iaCPT 87340$150
Hepatitis c ab testCPT 86803$154
Hepatitis c revrs trnscrpjCPT 87522$620
Heterophile antibody screenCPT 86308$147
Hiv-1/hiv-2 1 result antbdyCPT 86703$154
Hla ii typing 1 locus lrCPT 81376$405
Hpv high-risk typesCPT 87624$231
Immunoassay nonantibodyCPT 83516$165
Immunofix e-phoresis serumCPT 86334$323
Immunohisto antb 1st stainCPT 88342$674
Influenza dna amp probeCPT 87502$641
Iron binding testCPT 83550$124
Kidney function panel testCPT 80069$106
Lactate (ld) (ldh) enzymeCPT 83615$86
Liver function blood testCPT 80076$114
Lyme disease antibodyCPT 86618$180
Lyme disease antibodyCPT 86617$218
Microbe susceptible micCPT 87186$151
Microscopic exam of urineCPT 81015$42
Mumps antibodyCPT 86735$190
N.gonorrhoeae dna amp probCPT 87591$371
Obstetric blood test panel (Not Offered)CPT 80055--
Organic acid single quantCPT 83921$262
Particle agglut antbdy scrnCPT 86403$116
Protein e-phoresis serumCPT 84165$134
Rbc antibody screenCPT 86850$153
Rbc sed rate nonautomatedCPT 85651$50
Resp virus 3-5 targetsCPT 87631$306
Reticyte/hgb concentrateCPT 85046$64
Rheumatoid factor quantCPT 86431$83
Routine venipunctureCPT 36415$30
Rubella antibodyCPT 86762$193
Rubeola antibodyCPT 86765$186
Smear gram stainCPT 87205$63
Stool cultr aerobic bact eaCPT 87046$114
Strep a dna amp probeCPT 87651$297
Tb test cell immun measureCPT 86480$656
Tissue exam by pathologistCPT 88305$747
Tissue exam by pathologistCPT 88304$554
Total prostate-specific antigen (PSA) testCPT 84153$220
Total prostate-specific antigen (PSA) testCPT 84154$266
Ur albumin quantitativeCPT 82043$68
Urinalysis testCPT 81003$36
Urinalysis testCPT 81002$18
Urinalysis test using microscopeCPT 81001$46
Urinalysis test using microscope (Not Offered)CPT 81000--
Urine culture/colony countCPT 87086$66
Urine pregnancy testCPT 81025$90
Varicella-zoster antibodyCPT 86787$186
Vitamin b-12CPT 82607$151
Vitamin d 25 hydroxyCPT 82306$237
MRI ScanCPT 70553$4,979
MRI scan of leg jointCPT 73721$3,389
MRI scan of lower spinal canalCPT 72148$3,218
Mri brain stem w/o dyeCPT 70551$3,507
Other Diagnostic
Extracranial bilat studyCPT 93880$714
Extremity studyCPT 93971$574
Home sleep test/type 3 portaHCPCS G0399$507
Musc test done w/n test compCPT 95886$512
Musc tst done w/nerv tst limCPT 95885$426
Nrv cndj test 7-8 studiesCPT 95910$621
Nrv cndj test 9-10 studiesCPT 95911$866
Nrv cndj tst 5-6 studiesCPT 95909$544
Slp stdy unattendedCPT 95800$194
Vascular studyCPT 93976$729
Other Therapeutic
Blood transfusion serviceCPT 36430$550
Cardiac rehab/monitorCPT 93798$278
PhlebotomyCPT 99195$142
Pulmonary rehab w exerHCPCS G0424$171
Rbc leukocytes reducedHCPCS P9016$542
Family psychotherapy, including patient, 50 min (Not Offered)CPT 90847--
Family psychotherapy, not including patient, 50 minCPT 90846$264
Group psychotherapy (Not Offered)CPT 90853--
Psychotherapy, 30 minCPT 90832$164
Psychotherapy, 45 minCPT 90834$217
Psychotherapy, 60 minCPT 90837$327
Pulmonary Function
Co/membane diffuse capacityCPT 94729$253
Evaluation of wheezingCPT 94060$310
Pulm funct tst plethysmograpCPT 94726$326
Dxa bone density axialCPT 77080$670
X-Ray of lower backCPT 72110$802
X-ray exam abdomen 1 viewCPT 74018$326
X-ray exam chest 1 viewCPT 71045$298
X-ray exam chest 2 viewsCPT 71046$406
X-ray exam complete abdomenCPT 74022$662
X-ray exam hip uni 2-3 viewsCPT 73502$860
X-ray exam l-s spine 2/3 vwsCPT 72100$586
X-ray exam neck spine 4/5vwsCPT 72050$750
X-ray exam of ankleCPT 73610$484
X-ray exam of finger(s)CPT 73140$495
X-ray exam of footCPT 73630$470
X-ray exam of handCPT 73130$477
X-ray exam of knee 1 or 2CPT 73560$429
X-ray exam of knee 3CPT 73562$537
X-ray exam of shoulderCPT 73030$420
X-ray exam thorac spine 2vwsCPT 72070$462
X-rays at surgery add-onCPT 74301$467
Airway inhalation treatmentCPT 94640$151
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$2,325
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--
Aquatic therapy/exercisesCPT 97113$213
Gait training therapyCPT 97116$138
Manual therapy 1/> regionsCPT 97140$145
Neuromuscular reeducationCPT 97112$163
Ot eval low complex 30 minCPT 97165$293
Ot eval mod complex 45 minCPT 97166$355
Physical therapy, therapeutic exerciseCPT 97110$156
Pt eval low complex 20 minCPT 97161$293
Pt eval mod complex 30 minCPT 97162$355
Self care mngment trainingCPT 97535$170
Therapeutic activitiesCPT 97530$170
Ultrasound therapyCPT 97035$62
Wheelchair mngment trainingCPT 97542$148
Admin influenza virus vacHCPCS G0008$36
Admin pneumococcal vaccineHCPCS G0009$36