Services Pricing
The following is a list of some common services/procedures performed at Weeks Medical Center. It is important to note that these are price estimates. There may be additional related procedures, tests, treatments, or supplies provided and billed seperately. Patients may call 603-788-5354 to discuss more specific billing rates and procedures.
| Emergency Department | CPT Code | Technical Component | Professional Component | Total |
| ED Room Level I | 99281 | $253.00 | $44.00 | $297.00 |
| ED Room Level II | 99282 | $466.00 | $84.00 | $550.00 |
| ED Room Level III | 99283 | $833.00 | $126.00 | $959.00 |
| ED Room Level IV | 99284 | $1,390.00 | $239.00 | $1,629.00 |
| ED Room Level V | 99285 | $2,175.00 | $353.00 | $2,528.00 |
| ED Room Critical Care 1st hour | 99291 | $2,832.00 | $564.00 | $3,396.00 |
| ED Room Critical Care each Additional 30 min | 99292 | $326.00 | $251.00 | $577.00 |
| Primary Care Physician Office | CPT Code | Technical Component | Professional Component | Total |
| Established | ||||
| Clinic Visit – established | 99211 | $46.00 | $46.00 | |
| Clinic Visit – established | 99212 | $84.00 | $84.00 | |
| Clinic Visit – established | 99213 | $140.00 | $140.00 | |
| Clinic Visit – established | 99214 | $205.00 | $205.00 | |
| Clinic Visit – established | 99215 | $276.00 | $276.00 | |
| New Patient | ||||
| Clinic Visit – new patient | 99202 | $143.00 | $143.00 | |
| Clinic Visit – new patient | 99203 | $206.00 | $206.00 | |
| Clinic Visit – new patient | 99204 | $314.00 | $314.00 | |
| Clinic Visit – new patient | 99205 | $393.00 | $393.00 | |
| Radiology | CPT Code | Technical Component | Professional Component | Total |
| X-Ray | ||||
| Chest Single Views | 71010 | $117.00 | $19.00 | $136.00 |
| Chest 2 Views | 71020 | $160.00 | $23.00 | $183.00 |
| Neck & Spine 4 Views | 72050 | $266.00 | $34.00 | $300.00 |
| Lower Spine | 72100 | $197.00 | $25.00 | $222.00 |
| Pelvis 1 or 2 Views | 72170 | $170.00 | $20.00 | $190.00 |
| Femur | 73552 | $170.00 | $20.00 | $190.00 |
| Knee 1 or 2 Views | 73560 | $175.00 | $20.00 | $195.00 |
| Knee 3 Views | 73562 | $223.00 | $21.00 | $244.00 |
| Foot 2 Views | 73630 | $189.00 | $18.00 | $207.00 |
| Abdomen Complete | 74020 | $223.00 | $29.00 | $252.00 |
| Esophagus | 74220 | $561.00 | $48.00 | $609.00 |
| CAT Scan | ||||
| Scan Head without Contrast | 70450 | $655.00 | $89.00 | $744.00 |
| Maxillofacial without Contrast | 70486 | $1,010.00 | $118.00 | $1,128.00 |
| Scan Chest without Contrast | 71250 | $1,083.00 | $118.00 | $1,201.00 |
| Chest with Contrast | 71260 | $1,425.00 | $129.00 | $1,554.00 |
| Scan Pelvis without Contrast | 72192 | $778.00 | $113.00 | $891.00 |
| Scan Abdomen without Contrast | 74150 | $761.00 | $123.00 | $884.00 |
| Abdomen Angiogram | 74175 | $2,332.00 | $195.00 | $2,527.00 |
| MRI | ||||
| Angiography Head without Contrast | 70544 | $2,783.00 | $125.00 | $2,908.00 |
| Brain without Contrast | 70551 | $1,376.00 | $153.00 | $1,529.00 |
| Brain With and without contrast | 70553 | $2,240.00 | $239.00 | $2,479.00 |
| Cervical Spine without Contrast | 72141 | $1,356.00 | $162.00 | $1,518.00 |
| Thoracic Spine without Contrast | 72146 | $1,356.00 | $162.00 | $1,518.00 |
| Lumbar Spine without Contrast | 72148 | $1,356.00 | $154.00 | $1,510.00 |
| Cervical Spine with and without Contrast | 72156 | $2,243.00 | $260.00 | $2,503.00 |
| Thoracic Spine with and without Contrast | 72157 | $2,246.00 | $261.00 | $2,507.00 |
| Lumbar Spine with and without Contrast | 72158 | $2,229.00 | $239.00 | $2,468.00 |
| Pelvis with and without Contrast | 72197 | $3,288.00 | $234.00 | $3,522.00 |
| Lower Extremity with and without Contrast | 73720 | $3,309.00 | $222.00 | $3,532.00 |
| Lower Extremity without Contrast | 73721 | $1,496.00 | $142.00 | $1,638.00 |
| Ultrasound | ||||
| Breast | 76641 | $601.00 | $76.00 | $677.00 |
| Abdomen | 76700 | $813.00 | $84.00 | $897.00 |
| Transvaginal | 76830 | $741.00 | $73.00 | $814.00 |
| Carotid Duplex Scan Bilateral | 93880 | $1,523.00 | $83.00 | $1,606.00 |
| Other | ||||
| Bone Density Study | 77080 | $312.00 | $22.00 | $334.00 |
| Mammography Digital Screening | G0202/77051 | $916.00 | $72.00 | $988.00 |
| Laboratory | CPT Code | Technical Component | Professional Component | Total |
| Venous Specimen Collection Fee | 36415 | $17.00 | $17.00 | |
| Basic Metabolic Panel | 80048 | $64.00 | $64.00 | |
| Lipid Panel | 80061 | $102.00 | $102.00 | |
| Liver Function Profile | 80076 | $62.00 | $62.00 | |
| Urinalysis | 81001 | $24.00 | $24.00 | |
| Hemoglobin A1C | 83036 | $74.00 | $74.00 | |
| Prostate Specific antigen (PSA) Total or Screening | G0103/84153 | $110.00 | $110.00 | |
| Thyroid Stimulating Hormone | 84443 | $127.00 | $127.00 | |
| Beta HCG – Pregnancy blood count | 84702 | $114.00 | $114.00 | |
| Compete Blood Count w WBC Count | 85025 | $59.00 | $59.00 | |
| Complete Blood Count with Differential | 85027 | $49.00 | $49.00 | |
| Prothrombin Time | 85610 | $30.00 | $30.00 | |
| Culture Urine | 87086 | $49.00 | $49.00 | |
| Outpatient Procedure | CPT Code | Technical Component | Professional Component | Total |
| Echocardiogram | 93306 | $2,554 | $256.00 | $2,810.00 |
| Colonoscopy Screening | GO121 | $1,564.00 | $762.00 | $2,326.00 |
