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Out-of-Pocket Estimator (How much will I owe?)

Please complete the following FOUR STEPS to receive an estimate of the out-of-pocket cost of some of our most common services. If you cannot find your service, please call Patient Accounts Customer Service at (800) 368-4783 to receive an estimate for any of the services we offer at Dartmouth-Hitchcock Medical Center.

STEP 1 - Choose Your Service:

A Doctor's Office and Emergency Department Visit (such as a routine annual physical) A Diagnostic Test (such as a blood test or x-ray) A Surgery, Procedure, Medical Condition, or Hospital Stay (such as a knee replacement or pneumonia)

STEP 1a - Choose a Doctor's Office and Emergency Department Visit:

Doctor's Office Visit for a New Patient   Pick a complexity level for your visit to get an idea of your cost       Low-Level Visit       Low-to-Moderate-Level Visit       Moderate-Level Visit       Moderate-to-High-Level Visit       High-Level Visit   Doctor's Office Visit for an Established Patient   Pick a complexity level for your visit to get an idea of your cost       Low-Level Visit       Low-to-Moderate-Level Visit       Moderate-Level Visit       Moderate-to-High-Level Visit       High-Level Visit   Doctor's Office Visit for Consultation   Pick a complexity level for your visit to get an idea of your cost       Low-Level Visit       Low-to-Moderate-Level Visit       Moderate-Level Visit       Moderate-to-High-Level Visit       High-Level Visit   Routine Annual Physical for a New Patient       New Patient Physical: Age 0 - 1       New Patient Physical: Age 1 - 4       New Patient Physical: Age 5 - 11       New Patient Physical: Age 12 - 17       New Patient Physical: Age 18 - 39       New Patient Physical: Age 40 - 64       New Patient Physical: Age 65 and over   Routine Annual Physical for an Established Patient       Established Patient Physical: Age 0 - 1       Established Patient Physical: Age 1 - 4       Established Patient Physical: Age 5 - 11       Established Patient Physical: Age 12 - 17       Established Patient Physical: Age 18 - 39       Established Patient Physical: Age 40 - 64       Established Patient Physical: Age 65 and over   Emergency Department Visit   Pick a complexity level for your visit to get an idea of your cost       Low-Level Visit       Low-to-Moderate-Level Visit       Moderate-Level Visit       Moderate-to-High-Level Visit       High-Level Visit   Eye Exams       New patient comprehensive eye exam       New patient intermediate eye exam       Established patient comprehensive eye exam       Established patient intermediate eye exam       Refraction test

STEP 1a - Choose a Diagnostic Test:

CT Scans       Abdominal CT scan       Chest CT scan       Head CT scan       Pelvis CT scan   Digestive, Intestinal, Gastroenterology       Colonoscopy screening       Colonoscopy with polyp removal       Endoscopy (upper gastrointestinal)   Lab Tests       Complete blood count (CBC)       Glucose test       Lipid profile       Pap test (with liquid base preparation)       Prostate specific antigen (PSA)       Strep test       Urinalysis (urine analysis)   Mammograms       Diagnostic mammogram with digitization & computer aided detection (both breasts)       Screening mammogram with digitization & computer aided detection (both breasts)   MRIs       Brain MRI       Knee MRI       Pelvis MRI       Spine MRI   PET Scans       Whole body scan   Pregnancy & Prenatal Tests       ABO type (blood typing)       Chlamydia test       Fetal non-stress test       Obstetric ultrasound       Pap test       Pregnancy test       Prenatal blood work       Rh type       Urine culture   Stress Tests & Echocardiograms       Echocardiogram (doppler)       Radiologic stress test       Stress test with echocardiogram (real-time image)   Ultrasounds       Obstetric ultrasound       Ultrasound, pelvis, complete   X-rays       Bone density scan (dexa scan)       Chest X-ray (two views)       Foot X-ray       Spine X-ray

STEP 1a - Choose a Surgery, Procedure, Medical Condition, or Hospital Stay:

Biopsies, Cancer       Breast core biopsy (non-surgical, image guided)   Bones, Muscles, Orthopaedics       Carpal tunnel release (one hand)       Hip replacement       Knee arthroscopy       Knee replacement (one knee)       Knee replacement (both knees)   Brain, Stroke, Seizure       Brain surgery       Seizures       Stroke   Digestive, Intestinal, Gastroenterology       Abdominal pain, gastrointestinal disorder (over age 17)       Bowel surgery       Colonoscopy screening       Colonoscopy with polyp removal       Endoscopy (upper gastrointestinal)       Gall bladder surgery (laparoscopic)   Ear, Nose, Throat       Ear tube placement (myringotomy)       Septoplasty (nostril wall repair)       Tonsillectomy and adenoidectomy (under age 12)   Eyes, Ophthalmology       Cataract extraction with lens implant (one eye)   Heart, Cardiology, Lung, Cardiovascular       Aorta surgery       Arrhythmia       Cardiac catheterization       Congestive heart failure       Coronary artery bypass graft (CABG) with catheterization       Heart attack with cardiac catheterization       Heart valve surgery       Lung surgery       Pacemaker insertion or replacement       PCI/Angioplasty with stent   Hernia       Hernia repair (inguinal) - age 5 and older   Pneumonia       Pneumonia (over age 17)   Pregnancy, Birth       C-section (includes normal newborn care)       Normal newborn care       Vaginal delivery (includes normal newborn care)

STEP 2 - Choose Your Insurance:

Medicare All other insurance No insurance

STEP 2a - Enter Your Insurance Information:

You may need to check with your insurance company if you are unsure about the answers. Their toll-free phone number should be located on your insurance card, or you can look at our list of insurance companies for contact information.

Enter your yearly deductible amount:   (Enter 0 if none) $   Enter your copay amount: (Enter 0 if none) $   Enter the coinsurance amount (percentage) you are responsible for:   No Coinsurance 10% 15% 20% 30% 50% Other   Other: % Enter your out-of-pocket maximum per calendar year: (Enter 0 if unlimited)   $

STEP 3 - Read Disclaimer and Check Box:

The estimated patient cost is based on the information entered. If you have requested an estimate for a surgical procedure, this estimate does not include: pre-procedure office visits post-procedure office visits diagnostic testing If you have met all or part of your deductible or maximum out-of-pocket expenses, the actual amount you owe may be different. Note: The estimated cost is not a guarantee of insurance coverage. Please check with your insurance company if you need help understanding your benefits for the service chosen. I HAVE READ THE DISCLAIMER AND UNDERSTAND THIS IS AN ESTIMATE ONLY. MY ACTUAL BALANCE MAY BE DIFFERENT.

STEP 4 - Click Button to Receive Estimate:

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Feedback: We are interested in your feedback and questions about this first version of our out-of-pocket estimator. Please send email to Out-of-Pocket Estimator Feedback to let us know your thoughts.