Financial Information

Financial Information

Weeks Medical Center Billing and Collections Policy

Financial Assistance Policy

Financial Assistance Policy Plain Language Summary

EMTALA Reporting Policy

Surprise Medical Bills

Good Faith Estimate

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.

Price Estimator Tool

For further information, please call the Weeks Medical Center Business Office at (603) 788-5354.

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