performed in setting:
 Inpatient |
Outpatient |
 Clinic |
Estimated Contracted Insurance Allowed Amount calculated with Aetna Medicare
$5,474.90
*The price reflected is generated on routine procedure costs.
The price given does not include fees pertaining to third party services including, but not limited to, physician, radiology, pathology, and anesthesia group charges. This price also does not include data unique to individuals such as deductibles, out of pocket maximums, copays, and secondary insurances.
How does your insurance compare?
| Estimated Gross Total Cost | Lowest Contracted Amount | Highest Contracted Amount | Your Insurance Contracted Amount |
|---|---|---|---|
| $8,140.65 | $4,070.33 | $8,140.65 | $5,474.90 |
Minimum Amount:
$4,070.33
$4,070.33
Maximum Amount:
$8,140.65
$8,140.65
What does this mean?
This number is the contracted, allowed amount that your insurance provider has agreed upon with our facilities. Your responsibility is calculated based on this number dependent on your individual plans. Factors individual to you include deductibles, co-insurances, copays and out of pocket maximums. For you conveniece, we have a calulator you can utilize to aid in your calculations.
Items:
| Item | Quantity | Cost (Per Unit) |
|---|---|---|
| ACETAMINOPHEN INJ | 1 | $175.00 |
| LIDOCAINE 2% INJ : 20MG/ML 10ML MPF | 1 | $20.00 |
| LIDOCAINE 2% INJ : 20MG/ML 2ML MPF | 1 | $20.00 |
| LIDOCAINE 2% INJ : 20MG/ML 5ML MPF | 1 | $20.00 |
| PROPOFOL 10MG/1ML : 200MG/20ML | 1 | $20.00 |
| IV SOL LACT RINGERS 1000 2B2324X | 1 | $63.00 |
| ANES SUPP 1.5 | 1 | $827.00 |
| BANDAGE ACE 2 | 1 | $6.00 |
| CAST PAD 2 WEBRIL | 1 | $72.00 |
| INSTRUMENT TRAY SET | 2 | $226.00 |
| SPLINT FINGER 6 | 1 | $17.00 |
| SUT ETHILON 5-0 P-3 698G | 1 | $15.00 |
| TED STOCKINGS KNEE HIGH (ALL) | 1 | $35.00 |
| TOURN CUFF 18 DUAL PORT/SING BLAD 18 | 1 | $100.00 |
| BANDAGE ESMARK 6 LATEX FREE | 1 | $65.00 |
| DRAPE C-ARM SMALL | 1 | $50.00 |
| DRAPE U SPLIT STERILE | 1 | $21.00 |
| DRESSING COBAN 1 NON LATEX | 1 | $11.00 |
| DRESSING SPONGE 4X4 STERILE | 3 | $6.00 |
| DRESSING XEROFORM 5X9 | 1 | $9.00 |
| GOWN STER W/TOWEL XL | 5 | $23.00 |
| IRRIG SOL NACL 1000 2F7124 | 1 | $7.00 |
| IV ADMIN SET PRIMARY | 1 | $64.00 |
| IV ADMIN SET SECONDARY | 1 | $24.00 |
| PACK BASIC | 1 | $34.00 |
| SHEET EXTREMITY/LIMB | 1 | $43.00 |
| TUBING SUCT 12 | 1 | $17.00 |
| IMPLANT FINGER | 1 | $2606.40 |
| K WIRE .062 | 1 | $66.00 |
| OPERATING ROOM 1 HR | 1 | $1874.00 |
| CEFAZOLIN (ANCEF) INJ : 1 GRAM VIAL | 2 | $20.00 |
| CEFAZOLIN/D5W : 2 | 1 | $99.25 |
| DEXAMETHASONE(DECADRON) INJ : 4MG/1ML | 2 | $20.00 |
| DROPERIDOL (INAPSINE) INJ : 5MG/2ML | 1 | $20.00 |
| FENTANYL INJ : 50MCG/ML 2ML | 1 | $20.00 |
| KETALAR VIAL : 500MG/10ML | 1 | $24.00 |
| MIDAZOLAM INJ 2MG/2ML ANES | 1 | $20.00 |
| ROPIVACAINE 0.5%(NA | 1 | $77.00 |
| ZOFRAN INJ : 4MG/2ML | 2 | $20.00 |
| SOD CITRATE/CITRIC | 1 | $12.00 |
| PACU 1 HR | 1 | $882.00 |
| Standard Itemized Estimate, Excluding Fees: | $8,140.65 |
Potential Additional Fees
| Physician's Fee | $* |
| Anesthesia | If services rendered, may be billed separately. |
| Pathology | If services rendered, may be billed separately. |
*The physician's fee may be billed separately. Any value represented in this area is derived from fees expressed by providers in the Jackson Hospital Physician's group at our facility. Any procedure performed at our facility by a provider outside of our physician group is subject to bill service fees separately. This fee is not a representation of any anesthesia or pathology charges which may also be billed separately.
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