Financial Information
Financial Information
Weeks Medical Center Billing and Collections Policy
Financial Assistance Policy Plain Language Summary
Financial Assistance and Discounted/Sliding Fee Scale
Weeks Health Access is a local financial assistance program to help you with the care you need when you need it most. Patients who meet criteria for participation can receive help with their medical bills for services received at Weeks Medical Center facilities. In addition, if patients further qualify, they may also enroll in our Pharmaceutical Assistance Program, which can provide needed medications at greatly reduced prices. For complete guideline information: Weeks Health Access/NH Health Access Program.
Who qualifies?
Any patients who lives within our catchment area, which includes all of New Hampshire and Vermont and Oxford County, Maine.
How to apply.
Follow these steps:
- Complete financial forms: Financial Assistance application (PDF)
- Submit forms, including NHHA Checklist (PDF) with copies of income (paycheck stubs, Social Security benefit statement).
- Submit copy of a recent tax return
- Submit a copy of liquid assets (checking and or savings account statement, Certificates of Deposits, etc.).
- Sign IRS Form 4506T (PDF)
Is there a cost to me?
There may be a co-pay for medical care or handling charge for the Pharmaceutical Assistance Program. The amount is based on your income and assets. You are expected to present the co-pay at the time you receive service.
What help can I get?
- Bills incurred at Weeks Medical Center for non-elective services with the hospital or doctor’s office (lab, x-ray, room charges)
- Doctor bills for providers employed by Weeks Medical Center
- Weeks applies on your behalf to the drug companies for help with medications. Each company has its own criteria; therefore, approval for participation in the WHA program does not guarantee approval by the pharmaceutical companies.
Provider Appendix
Participating and Non-Participating Providers in the Weeks Medical Center Financial Assistance Program
Participating Providers
- Weeks Medical Center Emergency Room Providers
- Weeks Medical Center Clinic Providers, including Behavioral Health – Lancaster, Whitefield, Groveton, Colebrook, Littleton, Berlin, and North Stratford Locations
- Weeks Medical Center Podiatrists
- Weeks Medical Center Hospitalists
- Weeks Medical Center Orthopedics
- Weeks Medical Center Surgeons
- Weeks Medical Center Urology Services – Dr. Rittenhouse
- Weeks Medical Center Pulmonology – Dr. Nordstrom
- Dartmouth-Hitchcock Oncologists
Non Participating Providers
Please note, these providers/hospitals may offer financial assistance through their own programs. Please contact them directly if you do receive a bill for services incurred at Weeks Medical Center.
- New England Heart and Vascular Institute Physicians
- Dartmouth-Hitchcock Medical Center Pathology
- Catholic Medical Center Cardiology
- Coos North Country Radiology, PLLC
- Androscoggin Valley Hospital Specialists
- Dr. Simon; Pulmonologist
- Dr. DellaValla; Sleep Medicine
- Dr. Kardell & Tiffany Witmon, PAC; ENT
Services Pricing
The following is a list of some common services/procedures performed at Weeks Medical Center. For a full copy of our chargemaster, please see the link at the bottom of this page. It is important to note that these are price estimates. There may be additional related procedures, tests, treatments, or supplies provided and billed separately. Patients may call (603) 788-5354 to discuss more specific billing rates and procedures.
**All Radiology related professional component fees will be charged by Coos North Country Radiology and will be billed separately.
| Emergency Department | CPT Code | Technical Component | Professional Component | Total |
| ED Room Level I | 99281 | $340.00 | $45.00 | $385.00 |
| ED Room Level II | 99282 | $640.00 | $107.00 | $747.00 |
| ED Room Level III | 99283 | $1,090.00 | $159.00 | $1,249.00 |
| ED Room Level IV | 99284 | $1,690.00 | $300.00 | $1,990.00 |
| ED Room Level V | 99285 | $2,440.00 | $365.00 | $2,805.00 |
| ED Room Critical Care 1st hour | 99291 | $3,340.00 | $576.00 | $3,916.00 |
| ED Room Critical Care each Additional 30 min | 99292 | $508.00 | $257.00 | $765.00 |
| Primary Care Physician Office | CPT Code | Technical Component | Professional Component | Total |
| Established | ||||
| Clinic Visit – established | 99211 | $47.00 | $47.00 | |
| Clinic Visit – established | 99212 | $90.00 | $90.00 | |
| Clinic Visit – established | 99213 | $146.00 | $146.00 | |
| Clinic Visit – established | 99214 | $214.00 | $214.00 | |
| Clinic Visit – established | 99215 | $286.00 | $286.00 | |
| New Patient | ||||
| Clinic Visit – new patient | 99202 | $151.00 | $151.00 | |
| Clinic Visit – new patient | 99203 | $214.00 | $214.00 | |
| Clinic Visit – new patient | 99204 | $323.00 | $323.00 | |
| Clinic Visit – new patient | 99205 | $405.00 | $405.00 | |
| Radiology | CPT Code | Technical Component | Professional Component | Total |
| X-Ray | ||||
| Chest Single Views | 71045 | $167.00 | ** | $167.00 |
| Chest 2 Views | 71046 | $306.00 | ** | $306.00 |
| Neck & Spine 4 Views | 72050 | $462.00 | ** | $462.00 |
| Lower Spine | 72100 | $373.00 | ** | $373.00 |
| Pelvis 1 or 2 Views | 72170 | $362.00 | ** | $362.00 |
| Femur | 73552 | $368.00 | ** | $368.00 |
| Knee 1 or 2 Views | 73560 | $357.00 | ** | $357.00 |
| Knee 3 Views | 73562 | $412.00 | ** | $412.00 |
| Foot 2 Views | 73630 | $329.00 | ** | $329.00 |
| Abdomen Complete | 74019 | $340.00 | ** | $340.00 |
| Esophagus | 74220 | $638.00 | ** | $638.00 |
| CAT Scan | ||||
| Scan Head without Contrast | 70450 | $1234.00 | ** | $1234.00 |
| Maxillofacial without Contrast | 70486 | $1,895.00 | ** | $1,895.00 |
| Scan Chest without Contrast | 71250 | $1,618.00 | ** | $1,618.00 |
| Chest with Contrast | 71260 | $1,935.00 | ** | $1,935.00 |
| Scan Pelvis without Contrast | 72192 | $1895.00 | ** | $1,895.00 |
| Scan Abdomen without Contrast | 74150 | $1895.00 | ** | $1,895.00 |
| Abdomen Angiogram | 74175 | $3,235.00 | ** | $3,235.00 |
| MRI | ||||
| Angiography Head without Contrast | 70544 | $3,066.00 | ** | $3,066.00 |
| Brain without Contrast | 70551 | $3,066.00 | ** | $3,066.00 |
| Brain With and without contrast | 70553 | $6,501.00 | ** | $6,501.00 |
| Cervical Spine without Contrast | 72141 | $3,547.00 | ** | $3,547.00 |
| Thoracic Spine without Contrast | 72146 | $3,537.00 | ** | $3,547.00 |
| Lumbar Spine without Contrast | 72148 | $3,547.00 | ** | $3,547.00 |
| Cervical Spine with and without Contrast | 72156 | $6,501.00 | ** | $6,501.00 |
| Thoracic Spine with and without Contrast | 72157 | $6,501.00 | ** | $6,501.00 |
| Lumbar Spine with and without Contrast | 72158 | $6,501.00 | ** | $6,501.00 |
| Pelvis with and without Contrast | 72197 | $6,412.00 | ** | $6,412.00 |
| Lower Extremity with and without Contrast | 73720 | $6,393.00 | ** | $6,393.00 |
| Lower Extremity without Contrast | 73721 | $3,018.00 | ** | $3,018.00 |
| Ultrasound | ||||
| Breast | 76641 | $701.00 | ** | $701.00 |
| Abdomen | 76700 | $811.00 | ** | $811.00 |
| Transvaginal | 76830 | $863.00 | ** | $863.00 |
| Carotid Duplex Scan Bilateral | 93880 | $1,141.00 | ** | $1,141.00 |
| Other | ||||
| Bone Density Study | 77080 | $607.00 | ** | $607.00 |
| Mammography Digital Screening | G0202/77051 | $1,182.00 | ** | $1,182.00 |
| Laboratory | CPT Code | Technical Component | Professional Component | Total |
| Venous Specimen Collection Fee | 36415 | $22.00 | $22.00 | |
| Basic Metabolic Panel | 80048 | $75.00 | $75.00 | |
| Lipid Panel | 80061 | $190.00 | $190.00 | |
| Liver Function Profile | 80076 | $85.00 | $85.00 | |
| Urinalysis | 81001 | $60.00 | $60.00 | |
| Hemoglobin A1C | 83036 | $86.00 | $86.00 | |
| Prostate Specific antigen (PSA) Total or Screening | G0103/84153 | $162.00 | $162.00 | |
| Thyroid Stimulating Hormone | 84443 | $172.00 | $172.00 | |
| Beta HCG – Pregnancy blood count | 84702 | $131.00 | $131.00 | |
| Compete Blood Count w WBC Count | 85025 | $65.00 | $65.00 | |
| Complete Blood Count with Differential | 85027 | $63.00 | $63.00 | |
| Prothrombin Time | 85610 | $55.00 | $55.00 | |
| Culture Urine | 87086 | $72.00 | $72.00 | |
| Outpatient Procedure | CPT Code | Technical Component | Professional Component | Total |
| Echocardiogram | 93306 | $1,338.00 | Charged by CMC | $1,338.00 |
| Colonoscopy Screening | GO121 | $714.00 | $778.00 | $1,492.00 |
Hospital Chargemaster
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 Weeks Medical Center posts on an annual basis. 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) 788-5354 for information about the cost of your care.
CLICK HERE for Hospital Chargemaster Information
Frequently Asked Questions About Pricing
CLICK HERE for FAQs About Pricing
Price Transparency
CLICK HERE for more information about Price Transparency.
For further information, please call the Weeks Medical Center Business Office at (603) 788-5354.