50 Union Street
Ellsworth, Maine 04605
207.664.5311
Toll free 888.645.8829
TTY 207.664.5600
www.mcmhospital.org
To Our Valued Patients:
At Maine Coast Memorial Hospital, we strive to provide the information you
need to understand every aspect of your care. In keeping with this promise, as
well as compliance with state law, Maine Coast is providing this price list for
our most frequently provided services. Maine Coast charges the same for all
patients, but depending on payment plans negotiated with individual health
insurers, your responsibility may vary. Additionally, if a patient is uninsured
or underinsured one of our financial counselors (207-664-5330) can help
determine eligibility for discounts.
These prices are correct as of September 1, 2016.
If you need additional information or prices for services not listed please
contact us at 207-664-5809 or 207-664-5311. In addition, you may contact
the Maine Health Data Organization (207-287-6722) https://mhdo.maine.gov)
for additional information.
Thank you for choosing Maine Coast Memorial Hospital
Ancillary Services - Price Listing
CARDIOPULMONARY SERVICES
CHARGE
CODE
DESCRIPTION
4100002 NEBULIZER TREATMENT
7300001 EKG (ELECTROCARDIOGRAM)
4100040 O2 SATURATION
FLUTTER VALVE-SUBSEQUENT
4600004 TREAT
CPT
CODE
94640
93005
94760
PRICE
$108.00
$148.78
$20.40
94668
$83.25
MAMMOGRAPHY SERVICES
CHARGE
CODE
4030003
4030002
4010005
4010002
4010001
DESCRIPTION
COMPUTER-AIDED DETECTION
SCRN
MAMMO, BILATERAL-SCREEN
COMPUTER-AIDED DETECTION DX
MAMMO, BILATERAL-DIAGNOSTIC
MAMMO, UNILATERAL-DIAGNOSTIC
CPT
CODE
PRICE
77052
77057
77051
77056
77055
$46.23
$234.73
$46.23
$560.06
$441.78
CPT
CODE
76830
76705
76816
93971
76645
PRICE
$451.50
$607.50
$609.00
$570.00
$319.80
ULTRASOUND SERVICES
CHARGE
CODE
4020022
4020001
4020005
4020026
4020010
DESCRIPTION
TRANSVAGINAL US
ABDOMEN US, LIMITED
OB F/U, REPEAT ULTRASOUND
DUPLEX EXT VEINS; UNIL/LIMIT
BREAST US
MRI SERVICES
CHARGE
CODE
6110015
6100033
6100022
6100031
6110017
DESCRIPTION
BRAIN MRI W/O CONTRAST
LOWER EXT, JOINT MRI
LUMBAR W/O CONTRAST
UPPER EXT, JOINT MRI W/O
BRAIN MRI W W/O CONTRAST
CPT
CODE
70551
73721
72148
73221
70553
PRICE
$1,785.55
$1,783.71
$1,385.00
$1,362.00
$2,759.66
MEDICAL IMAGING SERVICES
CHARGE
CODE
3200020
3200023
3500001
3500069
3200025
DESCRIPTION
CHEST X-RAY
CHEST XRAY; SINGLE VIEW
HEAD CT W/O CONTRAST
ABDOMEN/PELVIC CT W/CONTRAST
DEXA BONE DENSITY, AXIAL
CPT
CODE
PRICE
71020
$255.48
71010
$186.18
70450 $1,190.68
74177 $1,573.00
77080
$419.50
LABORATORY SERVICES
CHARGE
CODE
DESCRIPTION
3003095 PROTHOMBIN TIME
METABOLIC
3016287 PANEL;COMPREHENSIVE
3053119 CBC/AUTO-HMG+PLT+AUTO DIFF
3053776 COMPL AUTOM CBC W PLT
3016286 METABOLIC PANEL;BASIC
CPT
CODE
85610
PRICE
$36.90
80053
85025
85027
80048
$110.67
$58.00
$51.00
$89.35
Physician Services - Price Listing
OFFICE VISITS
CPT
CODE
99202
99203
99204
99205
99211
99212
99213
99214
99215
DESCRIPTION
NEW PATIENT OFFICE VISIT LEVEL 2
NEW PATIENT OFFICE VISIT LEVEL 3
NEW PATIENT OFFICE VISIT LEVEL 4
NEW PATIENT OFFICE VISIT LEVEL 5
ESTABLISHED PATIENT OFFICE VISIT LEVEL 1
ESTABLISHED PATIENT OFFICE VISIT LEVEL 2
ESTABLISHED PATIENT OFFICE VISIT LEVEL 3
ESTABLISHED PATIENT OFFICE VISIT LEVEL 4
ESTABLISHED PATIENT OFFICE VISIT LEVEL 5
PRICE
$ 136.00
$ 190.60
$ 280.60
$ 365.20
$ 81.00
$ 102.50
$ 133.80
$ 191.70
$ 258.20
PROCEDURES- Physician only
CPT
CODE
11100
20610
90471
10060
11301
17000
17003
17110
57454
58100
45380
20605
DESCRIPTION
SKIN BIOPSY
JOINT ASPIRATION AND/OR INJ MAJOR JOINT
IMMUNIZATION ADMINISTRATION
INCISION AND DRAINAGE ABSCESS
SHAVE LESION,SINGLE,TRUNK/EXT;0.6-1.0 CM
DESTRUCTION ALL BENIGN/PREMALIG LES,1ST
CRYOSURGERY SECOND THROUGH 14 LESIONS
CRYOSURG REMOVAL FLAT LESIONS, UP TO 14
COLPOSCOPY WITH BIOPSY
ENDOMETRIAL BIOPSY
COLONOSCOPY, FLEXIBLE, WITH BIOPSY
ASPIRATION AND/OR INTERMED. JOINT
PRICE
$ 151.90
$ 166.10
$ 19.42
$ 192.60
$ 168.50
$ 123.20
$ 32.70
$ 116.50
$ 315.40
$ 318.20
$ 493.50
$ 142.80