Hospital Departments Laboratory Services Basic Metabolic Panel (BMP)(80048) $88 N/A $88 $35 Blood draw (36415) $29 N/A $29 $12 Complete blood cell count (CBC)(85025) $88 N/A $88 $35 Comprehensive Metabolic Panel (CMP)(80053) $105 N/A $105 $42 C-reactive Protein (CRP)(86140) $76 N/A $76 $30 Creatinine, blood (82565) $70 N/A $70 $28 Ferritin (82728) $162 N/A $162 $65 Glucose, monitor (82962) $45 N/A $45 $18 Hemoglobin A1C (HgA1C)(83036) $102 N/A $102 $41 Iron (83540) $57 N/A $57 $23 Lipase (83690) $107 N/A $107 $43 Lipid Panel (80061) $116 N/A $116 $46 Liver Function Panel (80076) $90 N/A $90 $36 Magnesium (83735) $105 N/A $105 $42 Microalbumin, urine (82043) $105 N/A $105 $42 Prothrombin Time (85610) $65 N/A $65 $26 Prostate-Specific Antigen (PSA)(84153) $162 N/A $162 $65 Red Blood Cell Sedimentation Rate (85652) $62 N/A $62 $25 Semen Analysis (89321) $458 N/A $458 $183 Thyroid Stimulating Hormone (TSH)(84443) $149 N/A $149 $60 Thyroxine, free T4 (84439) $148 N/A $148 $59 Troponin, quantitative (84484) $162 N/A $162 $65 Urinalysis w/ microscopy (81001) $62 N/A $62 $25 Urinalysis, Dip stick or reagant (81003) $29 N/A $29 $12 Urine Culture (87086) $92 N/A $92 $37 Urine Toxicology Screen - Cup, Optical Read (80305) $46 N/A $46 $18 Urine Toxicology Screen - Instrument Assisted (80306) $436 N/A $436 $174 Vitamin D 25-Hydroxy (82306) $228 N/A $228 $91 Cardiology Cardiac Stress Test (exercise induced) (93016-8) $1,368 $178 $1,546 $618 Cardiac Stress Test (drug induced) (93016-8) $2,625 $178 $2,803 $1,121 Cardiac Stress & Rest Myoview (exercise induced) (93016-8, 78452) $5,248 $449 $5,697 $2,279 Echocardiogram, complete (93306) $2,495 $215 $2,710 $1,084 Echocardiogram, complete w/ contrast (C8923) $3,414 $431 $3,845 $1,538 Echocardiogram, limited (93308) $803 $88 $891 $356 Echocardiogram, transesophageal (TEE)(93312) $2,412 $381 $2,793 $1,117 These prices are valid from 12/01/2017 through 09/30/2018 Page 1 of 8
Electrocardiogram (EKG or ECG) (93000) $258 $55 $313 $125 Holter Monitor < 48 hours (93225-7) $1,730 $123 $1,853 $741 Stress Echocardiogram (93351) $1,852 $290 $2,142 $857 Zio patch monitor > 48 hours (0296-8T) $1,705 $246 $1,951 $780 Sleep Studies Sleep Study (Diagnostic)(95810) $5,540 $415 $5,955 $2,382 Sleep Study w/ CPAP/BIPAP (95811) $6,264 $432 $6,696 $2,678 Home Sleep Study (95806) $605 $220 $825 $330 Radiology Services* *The prices below apply to Radiology services provided at Concord Hospital ONLY. For all other locations, contact contact the specific location. Bone Scans Bone Scan - Whole Body (78306) $3,107 X-Ray Professionals $3,107 $1,243 CT (CAT) Scans CT Abdomen w/o Contrast (74150) $2,940 X-Ray Professionals $2,940 $1,176 CT Abdomen w/ Contrast (74160) $3,536 X-Ray Professionals $3,536 $1,414 CT Abdomen w/ + w/o contrast (74170) $4,263 X-Ray Professionals $4,263 $1,705 CT Abd/Pel w/o Contrast (74176) $6,233 X-Ray Professionals $6,233 $2,493 CT Abd/Pel w/ Contrast (74177) $7,240 X-Ray Professionals $7,240 $2,896 CT Abd/Pel w/ + w/o contrast (74178) $8,293 X-Ray Professionals $8,293 $3,317 CT Brain w/o Contrast (70450) $2,517 X-Ray Professionals $2,517 $1,007 CT Chest w/o Contrast (71250) $3,203 X-Ray Professionals $3,203 $1,281 CT Chest w/ Contrast (71260) $3,973 X-Ray Professionals $3,973 $1,589 CT Chest w/ + w/o contrast (71270) $4,445 X-Ray Professionals $4,445 $1,778 CT Angio Chest (71275) $5,015 X-Ray Professionals $5,015 $2,006 CT Neck w/o Contrast (70490) $2,780 X-Ray Professionals $2,780 $1,112 CT Neck w/ Contrast (70491) $3,464 X-Ray Professionals $3,464 $1,386 CT Neck w/ + w/o contrast (70492) $4,104 X-Ray Professionals $4,104 $1,642 CT Angio Neck w/ + w/o contrast (70498) $4,495 X-Ray Professionals $4,495 $1,798 CT Pelvis w/o Contrast (72192) $3,155 X-Ray Professionals $3,155 $1,262 CT Pelvis w/ Contrast (72193) $3,735 X-Ray Professionals $3,735 $1,494 CT Pelvis w/ + w/o contrast (72194) $4,263 X-Ray Professionals $4,263 $1,705 CT Sinus (70486) $2,691 X-Ray Professionals $2,691 $1,076 CT Spine w/o Contrast (72125,72128,72131) $3,203 X-Ray Professionals $3,203 $1,281 CT Spine w/ Contrast (72126,72129,72132) $3,973 X-Ray Professionals $3,973 $1,589 CT Spine w/ + w/o Contrast (72127,72130,72133) $4,803 X-Ray Professionals $4,803 $1,921 These prices are valid from 12/01/2017 through 09/30/2018 Page 2 of 8
Mammograms Mammogram (Screening) $714 X-Ray Professionals $714 $286 MRIs MRI w/o Contrast (any 1 body part) $4,287 X-Ray Professionals $4,287 $1,715 MRI w/ Contrast (any 1 body part) $5,426 X-Ray Professionals $5,426 $2,170 MRI w + w/o Contrast (any 1 body part) $6,105 X-Ray Professionals $6,105 $2,442 X-Rays X-Ray Abdomen 1 View (74000) $373 X-Ray Professionals $373 $149 X-Ray Abdomen 2-3 Views (74020) $440 X-Ray Professionals $440 $176 X-Ray Abdomen 2-3 Views + Chest (74022) $723 X-Ray Professionals $723 $289 X-Ray Ankle 3 Views (73610) $466 X-Ray Professionals $466 $186 X-Ray Chest 1-View (71010) $368 X-Ray Professionals $368 $147 X-Ray Chest 2-Views (71020) $403 X-Ray Professionals $403 $161 X-Ray Foot 3 Views (73630) $466 X-Ray Professionals $466 $186 X-Ray Hand 3 Views (73130) $466 X-Ray Professionals $466 $186 X-Ray Hip w/ or w/o Pelvis, 1 View (73501) $621 X-Ray Professionals $621 $248 X-Ray Knee 4 Views (73564) $565 X-Ray Professionals $565 $226 X-Ray Pelvis 1-2 Views (72170) $570 X-Ray Professionals $570 $228 X-Ray Shoulder 2 Views (73030) $494 X-Ray Professionals $494 $198 X-Ray Spine 1 View (72020) $384 X-Ray Professionals $384 $154 X-Ray Spine 2-3 Views (72100) $590 X-Ray Professionals $590 $236 X-Ray Spine 4-5 Views (72050) $687 X-Ray Professionals $687 $275 X-Ray Wrist 3 Views (73110) $368 X-Ray Professionals $368 $147 Ultrasounds Ultrasound Abdomen (76700) $1,345 X-Ray Professionals $1,345 $538 Ultrasound Abdomen, limited (76705) $973 X-Ray Professionals $973 $389 Ultrasound Pelvis (76856) $1,086 X-Ray Professionals $1,086 $434 Ultrasound Pregnancy < 14 weeks (single)(76801) $1,817 X-Ray Professionals $1,817 $727 Ultrasound Pregnancy > 14 weeks (single)(76805) $1,211 X-Ray Professionals $1,211 $484 Ultrasound Renal (76775) $970 X-Ray Professionals $970 $388 Ultrasound Scrotal (76870) $1,048 X-Ray Professionals $1,048 $419 Ultrasound Thyroid (76536) $960 X-Ray Professionals $960 $384 Ultrasound Transvaginal (76830) $992 X-Ray Professionals $992 $397 These prices are valid from 12/01/2017 through 09/30/2018 Page 3 of 8
Hospital Room Rates Room Rates, per night Regular Room Rate $2,075 N/A $2,075 $830 Telemetry Room $2,645 N/A $2,645 $1,058 Behavioral Health Unit $3,325 N/A $3,325 $1,330 Intensive Care/ Coronary Care Unit $6,915 N/A $6,915 $2,766 Newborn Care $1,770-$3,000 N/A $1,770-$3,000 $708-$1,200 These prices are valid from 12/01/2017 through 09/30/2018 Page 4 of 8
Physician Practice Charges Physician Practice Visits Office Visit, New Patient (99203-99204) $111-$198 $176-$297 $287-$498 $115-$199 Office Visit, Established Patient (99213-99214) $118-$134 $89-$164 $207-$298 $83-$119 Office Consult (99243-99244) $136-$203 $222-$329 $358-$532 $143-$213 Physical, New Patient (Child < 18) (99381-4) $119-$136 $133-$189 $252-$325 $101-$130 Physical, Established Patient (Child < 18) (99391-4) $100-$129 $116-$158 $216-$287 $86-$115 Physical, New Patient Adult (18+)(99385-7) $129-$175 $184-$224 $313-$399 $125-$160 Physical, Established Patient Adult (18+) (99395-7) $114-$146 $145-$179 $259-$325 $104-$130 Physician Practice Vaccines Flu Vaccine $64 $22 $86 $34 Flu Vaccine, High Dose $174 $22 $196 $78 H Papilloma Vaccine (HPV) $360-$449 $22 $382-$471 $153-$188 Hepatitis A Vaccine, Adult $143 $22 $165 $66 Hepatitis A Vaccine, Pediatric/Adolescent $56 $22 $78 $31 Hepatitis B Vaccine, Adult $159 $22 $181 $72 Pneumococcal Vaccine $646 $22 $668 $267 TDAP Vaccine $78 $22 $100 $40 Zoster Vaccine $521 $22 $543 $217 Physician Practice Cardiology Electrocardiogram (EKG or ECG) (93000) $258 $55 $313 $125 Echocardiogram, complete (93306) $2,449 $215 $2,664 $1,066 Evaluation of Pacemaker - phone (93293) $88 $80 $168 $67 Evaluation of Pacemaker - in person (93288) $139 $53 $192 $77 Programming Dual Lead Pacemaker (93280) $278 $80 $358 $143 Remote Evaluation Pacemaker or ICD - transmissions (93295-6) $195 $203 $398 $159 Physician Practice Neurology Needle electromyography (EMG)(95886) $391 $587 $978 $391 EEG Awake & Asleep (95819) $2,070 $179 $2,249 $900 EEG Awake & Drowsy (95816) $1,419 $179 $1,598 $639 Nerve Conduction 3-4 studies (95908) $208 $312 $520 $208 Nerve Conduction 5-6 studies (95909) $250 $375 $625 $250 Physician Practice Pulmonary Measurement of lung diffusing capacity (94729) $410 $32 $442 $177 Determination of lung volumes (94726) $653 $116 $769 $308 These prices are valid from 12/01/2017 through 09/30/2018 Page 5 of 8
Spirometry - Breathing capacity test (94010) $163 $94 $257 $103 Physician Practice Urology Ultrasound Measure Bladder Capacity (51798) $71 $0 $71 $28 Cystoscopy (52000) $702 $211 $913 $365 Bladder Irrigation (51700) $246 $176 $422 $169 Insert Non-Indwelling Bladder Catheter (51701) $148 $94 $242 $97 Ultrasound Transrectal (76872) $751 $253 $1,004 $402 Physician Practice Other Procedures Drainage of Abscess (10060) $168 $251 $419 $168 Biopsy of single growth of skin and/or tissue (11100) $72 $142 $214 $86 Removal of skin tags (up to 15) (11200) $127 $123 $250 $100 Insertion of drug delivery implant (Contraceptive) $1,659 $324 $1,983 $793 Destruction of premalignant lesion, 1st (17000) $74 $110 $184 $74 Destruction of premalignant lesion, each addl (17003) $15 $24 $39 $16 Destruction of benign skin lesion (up to 14) (17110) $95 $142 $237 $95 Aspiration and/or injection of large joint (20610) $101 $146 $247 $99 Diagnostic anoscopy (46600) $162 $80 $242 $97 Insertion of intrauterine device (IUD)(58300) $185 $234 $419 $168 Removal of intrauterine device (IUD) (58301) $119 $180 $299 $120 Removal of impacted ear wax (69210) $99 $145 $244 $98 These prices are valid from 12/01/2017 through 09/30/2018 Page 6 of 8
Hospital Procedures Orthopaedics Total knee replacement (one knee) $58763-$69127 N/A $58763-$69127 $23505-$27651 Total hip replacement (one hip) $55346-$69127 N/A $55346-$69127 $22138-$27651 Low back disk surgery, 1 vertebral interspace $15325-$22712 N/A $15325-$22712 $6130-$9085 Pregnancy/ Birth Routine vaginal delivery, including antepartum and postpartum care $13595-$21659 $6,725 $20320-$28384 $8128-$11354 Routine vaginal delivery only $13595-$21659 $3,455 $17050-$25114 $6820-$10046 Cesarean delivery, including antepartum and postpartum care $20162-$28458 $7,621 $27783-$36079 $11113-$14432 Cesarean delivery only $20162-$28458 $3,983 $24145-$32441 $9658-$12976 Dilation and curettage, uterus $6682-$7029 $863 $7545-$7892 $3018-$3157 Care of miscarriage, first trimester $5299-$5991 $1,306 $6605-$7297 $2642-$2919 Cardiology Left heart catheter placement $37078-$48598 $2,407 $39485-$51005 $15794-$20402 Digestive, Intestinal, Gastroenterology Removal of appendix (Laparoscopic)(44970) $16130-$27075 $2,763 $18893-$29838 $7557-$11935 Removal of gallbladder (Laparoscopic)(47562, 47563) $28803-$34564 $3,077 $31880-$37641 $12752-$15056 Upper gastrointestinal endocopy with biopsy $3226-$3802 N/A $3226-$3802 $1290-$1521 Colonoscopy, diagnostic (45378) $2,770 $1,717 $4,305 $1,722 Colonoscopy, with biopsy or lesion removal (45380, 45384) $3,422 $1679-$1809 $5101-$5231 $2040-$2092 Urinary System Repair of bladder defect w/ sling (57288) $13825-$17282 $3,077 $16902-$20359 $6761-$8144 Cystoscopy w/ insertion of ureteral stent (52332) $7373-$11291 $1,857 $9230-$13148 $3692-$5259 Cystoscopy w/ biopsy (52204) $6913-$10600 $798 $7711-$11398 $3084-$4559 Cystoscopy w/ catheter (52005) $8065-$9217 $1,296 $9361-$10513 $3744-$4205 Cystoscopy w/ lithotripsy (52356) $12674-$25976 $1,706 $14380-$27682 $5752-$11073 Fragmenting of kidney stone (50590) $21315-$22236 $3,033 $24348-$25269 $9739-$10108 Laser prostate removal (52648) $9563-$16246 $3,184 $12747-$19430 $5099-$7772 Female Reproductive System & Breast Procedures Hysteroscopy w/biopsy (58558) $5416-$7834 $1,144 $6560-$8978 $2624-$3591 Partial mastectomy (19301) $6221-$8411 $2,321 $8542-$10732 $3417-$4293 Partial mastectomy w/removal of lymph nodes (19302) $14055-$19356 $3,648 $17703-$23004 $7081-$9202 Breast Lumpectomy/Biopsy (19120) $5069-$10945 $2,312 $7381-$13257 $2952-$5303 Breast Lumpectomy with ultrasound localization (19125) $6798-$10369 $1,644 $8442-$12013 $3377-$4805 These prices are valid from 12/01/2017 through 09/30/2018 Page 7 of 8
Hernia Repair initial inguinal hernia (49505) $9563-$17743 $2,052 $11615-$19795 $4646-$7918 Repair umbilical hernia (49585,49587) $8526-$11982 $1,587 $10113-$13569 $4045-$5428 Hernia repair (Laparoscopic)(49652) $17282-$25347 $3,869 $21151-$29216 $8460-$11686 General Surgery Biopsy or removal lymph nodes (38500) $4608-$12674 $913 $5521-$13587 $2208-$5435 Excision of benign lesion, trunk arm or legs > 4 cm (11406) $2984-$6913 $725 $3709-$7638 $1484-$3055 These prices are valid from 12/01/2017 through 09/30/2018 Page 8 of 8