Fee Estimates for Health Care Services

Average charges are estimates; your out-of-pocket expense will depend on your individual insurance coverage (such as co-insurance or deductibles).

Uninsured patients are eligible for a 40% reduction of charges. If you have questions, please contact Patient Accounts via email: patient.accounts@cheshire-med.com or by phone: (603) 354-5454 x4444.

These charges represent those of Dartmouth-Hitchcock Keene (DHK) and Cheshire Medical Center (CMC). There may be additional charges from other providers, such as Radiologists and Anesthesiologists depending on the services you receive.

Estimates valid between July 1, 2012 and June 30, 2013

Choose a visit type

Doctor's Office Visit for a New Patient (first visit or patients not seen within the past 3 years)
	D-HK Professional Charges	CMC Hospital Charges	Total Charge
Level 1*	$40	$76	$116
Level 2*	$77	$118	$195
Level 3*	$116	$143	$259
Level 4*	$166	$222	$389
Level 5*	$227	$261	$489

*The complexity level of your visit is based on the nature of your condition, paperwork, examination and counseling time. Actual level is assigned after your visit.

Doctor's Office Visit for an Established Patient (return visit for follow-up)
	D-HK Professional Charges	CMC Hospital Charges	Total Charge
Level 1*	$0	$76	$76
Level 2*	$41	$81	$122
Level 3*	$60	$108	$168
Level 4*	$94	$165	$259
Level 5*	$158	$211	$369

*The complexity level of your visit is based on the nature of your condition, paperwork, examination and counseling time. Actual level is assigned after your visit.

Doctor's Office Visit for Consultation (examination and coordination between healthcare providers)
	D-HK Professional Charges	CMC Hospital Charges	Total Charge
Level 1*	$230	$0	$230
Level 2*	$297	$0	$297
Level 3*	$379	$0	$379
Level 4*	$530	$0	$530
Level 5*	$681	$0	$681

*The complexity level of your visit is based on the nature of your condition, paperwork, examination and counseling time. Actual level is assigned after your visit.

Routine Annual Physical for New Patient (charge is based on age groups and does not include diagnostic testing)
	D-HK Professional Charges	CMC Hospital Charges	Total Charge
Age 0-1	$117	$158	$275
Age 1-4	$124	$167	$291
Age 5-11	$120	$185	$305
Age 12-17	$157	$194	$351
Age 18-39	$128	$217	$345
Age 40-64	$162	$228	$390
Age 65 and up	$178	$242	$420

Routine Annual Physical for Established Patient (charge is based on age groups and does not include diagnostic testing)
	D-HK Professional Charges	CMC Hospital Charges	Total Charge
Age 0-1	$94	$120	$214
Age 1-4	$111	$124	$235
Age 5-11	$101	$131	$232
Age 12-17	$124	$152	$276
Age 18-39	$103	$199	$302
Age 40-64	$120	$209	$329
Age 65 and up	$143	$220	$363

Eye Exams (Ophthalmology)
	D-HK Professional Charges	CMC Hospital Charges	Total Charge
New patient comprehensive*	$137	$129	$266
New patient intermediate*	$87	$84	$172
Established patient comprehensive*	$102	$103	$205
Established patient intermediate*	$60	$87	$147
Eye refraction	$0	$56	$56

*Definition of new or established patient: "A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the last three years."

Emergency Care Services (unscheduled emergency visit for patients requiring immediate medical attention) Charges do not include diagnostic testing such as lab services or X-rays. Charges do not include medications or observation charges. Call (603)354-5454 x4444 for more information.
	Professional Charges	CMC Hospital Charges	Total Charge
Level 1*	$81	$166	$247
Level 2*	$125	$255	$380
Level 3*	$198	$441	$639
Level 4*	$345	$685	$1030
Level 5*	$537	$881	$1,418

*The complexity level of your visit is based on the nature of your condition, paperwork, examination and counseling time. Actual level is assigned after your visit.

Maternity Care
	D-HK Professional Charges	CMC Hospital Charges	Total Charge
Vaginal delivery	$5,538	$5,842	$11,380
Newborn care	$312	$2,948	$3,260
Cesarean section	$6,186	$10,811	$16,997
Newborn care	$312	$3,652	$3,964
Tubal ligation w/c-section	$656	$0	$656
Discharge hospital	$215	$0	$215
Circumcision	$750	$2,368	$3,118
Level I OB ultrasound	$550	$0	$555
Newborn hearing test (pass/fail)	$190	$0	$190

Please note: All labs and ultrasounds are billed on a monthly basis as each patient's requirements differ. These fees are current and may change during the course of your pregnancy due to increases. Additional fees may be charged depending on the care required during your delivery. If these services are provided by anyone other than a Dartmouth-Hitchcock physician you will receive a bill from them. That provider will determine these fees. Please note that if you do not deliver at the Cheshire Medical Center you will be billed for any office visits you have had. Managed Care patients will be billed for any co-payments relating to office visits.

Colonoscopy, Upper Gastrointestinal Endoscopy & Sigmoidoscopy
	D-HK Professional Charges	CMC Hospital Charges	Total Charge
Colonoscopy, flexible*	$1,776	$3,121	$4,897
Colonoscopy, with removal by snare technique*	$2,769	$3,876	$6,645
Colonoscopy, flexible with biopsy*	$2,103	$3,504	$5,607
Sigmoidoscopy, flexible*	$565	$3,032	$3,597
Upper Gastrointestinal Endoscopy with biopsy*	$1,687	$3,492	$5,120

*Estimates do not include pathology testing or interpreting.

CMC and DHK are charitable health care organizations. We will treat patients who come to us for medically necessary care, regardless of their financial status. We offer financial assistance for these services - in the form of free or discounted care - to those patients who may have an inability to pay their bills. If you have any questions, would like an application for assistance or need to make payment arrangements, please contact Patient Financial Services at (603) 354-5454 x4444 Monday through Friday, 8:00 a.m. to 4:00 p.m.