Dartmouth-Hitchcock Medical Center

Provider Information

Services

• Ankle Repair - Arthroscopic

  SSP MS009

  up to

  $3,137

• Articular Finger Fracture Repair - Surgical

  SSP MS019

  up to

  $740

• Breast MRI

  SSP RA011

  up to

  $495

• Breast Ultrasound

  SSP RA012

  up to

  $202

• Bronchoscopy

  SSP PU000

  up to

  $1,355

• Carpal Tunnel Repair

  SSP NU002

  up to

  $2,331

• Cataract Removal with Intraocular Lens Insertion

  SSP OP000

  up to

  $4,551

• Colonoscopy

  SSP GA002

  up to

  $1,583

• Colonoscopy via Stoma

  SSP GA000

  up to

  $1,170

• CT

  SSP RA001

  up to

  $1,179

• CT of Abdomen and Pelvis

  SSP RA004

  up to

  $1,455

• Esophagogastroduodenoscopy, Simple

  SSP GA007

  up to

  $1,383

• Fetal MRI

  SSP RA006

  up to

  $389

• Fine Needle Aspiration Biopsy with Ultrasound Guidance

  SSP DE003

  up to

  $722

• Forearm/Wrist Repair - Non-Surgical

  SSP MS010

  up to

  $885

• Hernia Repair - Laparoscopic

  SSP GA010

  up to

  $2,554

• Hernia Repair - Non-Laparoscopic

  SSP GA011

  up to

  $2,563

• Hip Repair - Arthroscopic

  SSP MS008

  up to

  $3,713

• Hysteroscopy with Surgical Procedure

  SSP RE003

  up to

  $2,900

• Knee Repair - Arthroscopic

  SSP MS006

  up to

  $4,483

• Laparoscopic Surgery of Ovaries and/or Fallopian Tubes

  SSP RE004

  up to

  $3,296

• Mammogram

  SSP RA010

  up to

  $238

• MRI with Contrast

  SSP RA007

  up to

  $1,505

• MRI without Contrast

  SSP RA005

  up to

  $1,113

• Percutaneous Breast Biopsy

  SSP DE000

  up to

  $1,709

• Shoulder Repair, Complex - Arthroscopic

  SSP MS005

  up to

  $3,694

• Tonsil and Adenoid Removal (Child Under 12)

  SSP EN000

  up to

  $1,274

• Tonsil and/or Adenoid Removal

  SSP EN004

  up to

  $1,343

• Ultrasound

  SSP RA008

  up to

  $494

• X-Ray

  SSP RA000

  up to

  $427