Supplies, drugs & other prices at Dartmouth Hitchcock Medical Center
Lebanon, NH · every code in this section with a posted price and a Medicare benchmark.
67 codes. Prices are the hospital's own posted facility charges.
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| Procedure | Cash price | Gross charge | × Medicare |
|---|---|---|---|
| Alveoloplasty w/extract 1-3 (D7311) | $1,113.23 | $3,638 | 0.7× |
| Alveoplasty w/ extraction (D7310) | $1,113.23 | $3,638 | 0.7× |
| Bone replce graft first site (D4263) | $320.08 | $1,046 | 0.5× |
| Cone beam ct both jaws (D0383) | $372.71 | $1,218 | 3.3× |
| Cone beam ct capt & interp (D0364) | $372.71 | $1,218 | 3.3× |
| Cone beam ct interprete man (D0365) | $372.71 | $1,218 | 3.3× |
| Cone beam ct interprete max (D0366) | $372.71 | $1,218 | 3.3× |
| Esd endoscopy or colonoscopy (C9779) | $1,689.43 | $5,521 | 0.4× |
| Ev fempop artl revsc tcat plmt IV st grf & clsr (0505T) | $9,344.93 | $30,539 | 0.8× |
| Exposure of unerupted tooth (D7280) | $298.66 | $976 | 0.4× |
| Extraction erupted tooth/exr (D7140) | $298.66 | $976 | 0.4× |
| Fecal microbiota prep instil (G0455) | $93.33 | $305 | 0.1× |
| Fern test (Q0114) | $20.20 | $66 | 2.1× |
| Hbot, full body chamber, 30m (G0277) | $377.30 | $1,233 | 2.6× |
| Impact tooth rem bony w/comp (D7241) | $298.66 | $976 | 0.4× |
| Impact tooth remov comp bony (D7240) | $298.66 | $976 | 0.4× |
| Impact tooth remov part bony (D7230) | $298.66 | $976 | 0.4× |
| Impact tooth remov soft tiss (D7220) | $298.66 | $976 | 0.4× |
| Intraor comprehensive series (D0210) | $98.23 | $321 | 0.4× |
| Ire Ablation 1+Tumors per Organ W/Img Gdn Perq (0600T) unusually low: confirm this is the full procedure |
$3,709.03 | $12,121 | 0.3× |
| Neuro csf prion prtn qual (0035U) | $104.96 | $343 | 0.2× |
| Non-auto graft 1st tooth (D4275) | $342.41 | $1,119 | 0.2× |
| Obtaining screen pap smear (Q0091) | $13.77 | $45 | 0.4× |
| Oth resp proc, group (G0239) | $36.41 | $119 | 0.9× |
| Oth resp proc, indiv (G0238) | $45.29 | $148 | 1.5× |
| Pemivibart infusion (M0224) | $191.25 | $625 | 0.4× |
| Perc d-e cor revasc chro sin (C9607) | $9,828.72 | $32,120 | 0.5× |
| Perc d-e cor revasc t cabg s (C9604) | $6,726.19 | $21,981 | 0.5× |
| Perc d-e cor stent ather s (C9602) | $10,623.71 | $34,718 | 0.5× |
| Perc drug-el cor stent sing (C9600) | $7,402.45 | $24,191 | 0.6× |
| Periodontal scaling & root (D4341) | $98.23 | $321 | 0.1× |
| Perq Sacral Augmt Bilat Inj (0201T) likely a partial charge, not the full procedure |
$2,254.91 | $7,369 | 0.3× |
| Perq Sacral Augmt Unilat Inj (0200T) likely a partial charge, not the full procedure |
$1,571.62 | $5,136 | 0.2× |
| Pet not otherwise specified (G0235) | $1,530 | $5,000 | 3.6× |
| Place device/marker, non pro (C9728) | $663.10 | $2,167 | 0.4× |
| Prefabricated resin crown (D2932) | $179.62 | $587 | 0.3× |
| Prgrmg dev eval ldls pm single car chamber ip (0826T) | $127.91 | $418 | 3.2× |
| Prgrmg dev eval ldls pm sys 2chmbr in person (0804T) | $130.97 | $428 | 3.3× |
| Prgrmg Dev Eval Scrms Phys/Qhp Remote (0650T) | $138.92 | $454 | 3.5× |
| Prostate biopsy, any mthd (G0416) | $248.78 | $813 | 0.7× |
| Rem imp tooth w mucoper flp (D7210) | $298.66 | $976 | 0.2× |
| Revasc intra lithotrip-stent (C9765) unusually low: confirm this is the full procedure |
$8,509.25 | $27,808 | 0.4× |
| Revasc intravasc lithotripsy (C9764) unusually low: confirm this is the full procedure |
$4,730.15 | $15,458 | 0.4× |
| Root surgery molar (D3425) | $104.96 | $343 | 0.2× |
| Syphilis tst non-treponemal antibody ia qual rpr (0065U) | $28.76 | $94 | 1.6× |
| Tcat insj perm 1chmbr ldls pacemaker r atrial (0823T) | $10,575.05 | $34,559 | 0.5× |
| Tcat insj perm 2chmbr ldls pm r atr pm compnt (0796T) | $10,575.05 | $34,559 | 0.5× |
| Tcat insj perm 2chmbr ldls pm r ventr pm compnt (0797T) | $10,575.05 | $34,559 | 0.5× |
| Tcat Insj Perm Dual Chamber Ldls Pm Compl Sys (0795T) | $10,575.05 | $34,559 | 0.5× |
| Tcat rmvl perm 1chmbr ldls pacemaker r atrial (0824T) | $1,532.75 | $5,009 | 0.5× |
| Tcat rmvl perm 2chmbr ldls pm r atr pm compnt (0799T) | $1,532.75 | $5,009 | 0.5× |
| Tcat rmvl perm 2chmbr ldls pm r ventr pm compnt (0800T) | $1,532.75 | $5,009 | 0.5× |
| Tcat rmvl perm dual chamber ldls pm compl sys (0798T) | $1,532.75 | $5,009 | 0.5× |
| Tcat rmvl&rplcmt perm 1chmbr ldls pm r atrial (0825T) | $10,575.05 | $34,559 | 0.5× |
| Tcat rmvl&rplcmt perm 2chmbr ldls pm 2chmbr sys (0801T) | $10,575.05 | $34,559 | 0.5× |
| Tcat rmvl&rplcmt perm 2chmbr ldls pm r atr cmpnt (0802T) | $10,575.05 | $34,559 | 0.5× |
| Tcat rmvl&rplcmt prm 2chmbr ldls pm r vntr cmpnt (0803T) | $10,575.05 | $34,559 | 0.5× |
| Tcat Rmvl/Debulk Icar Mass Suction Device Perq (0644T) | $9,772.11 | $31,935 | 1.6× |
| Therapeutic procd strg endur (G0237) | $43.45 | $142 | 1.4× |
| Tomosynthesis, mammo (G0279) | $20.20 | $66 | 1.6× |
| Tpmt nudt15 gene analysis common variants (0034U) | $209.92 | $686 | 0.5× |
| Transcatheter Renal Sympath Denervation Bilat (0339T) | $20,285.35 | $66,292 | 3.3× |
| Transcatheter renal sympath denervation unilat (0338T) | $10,142.68 | $33,146 | 1.7× |
| Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation;… (0236T) likely a partial charge, not the full procedure |
$1,730.74 | $5,656 | 0.1× |
| Trauma respons w/hosp criti (G0390) | $1,443.71 | $4,718 | 1.0× |
| Trim nail(s) (G0127) | $31.21 | $102 | 0.5× |
| Unsched dialysis esrd pt hos (G0257) | $1,440.34 | $4,707 | 2.0× |