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 |
|---|---|---|---|
| $8,159.00 | $4,079.50 | $8,159.00 | $5,474.90 |
Minimum Amount:
$4,079.50
$4,079.50
Maximum Amount:
$8,159.00
$8,159.00
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 2ML MPF | 1 | $20.00 |
| PROPOFOL 10MG/1ML : 200MG/20ML | 1 | $20.00 |
| SEVOFLURANE LIQ : | 1 | $128.00 |
| SUFENTANIL(SUFENTA) | 1 | $21.75 |
| IV SOL LACT RINGERS 1000 2B2324X | 1 | $63.00 |
| IV SOLUTION ALL | 1 | $63.00 |
| ANES SUPP 1.5 | 1 | $827.00 |
| BANDAGE ACE 6 | 1 | $12.00 |
| CAST PAD 6 WEBRIL | 1 | $72.00 |
| GOWN STER XXL / X-L | 1 | $21.00 |
| INSTRUMENT TRAY SET | 3 | $226.00 |
| SCD PUMP SET UP & SLEEVE | 1 | $510.00 |
| STOCKINETTE IMPERVIOUS 12 STERILE | 1 | $17.00 |
| SUT ETHILON 4-0 PS-2 1667G | 1 | $15.00 |
| TED STOCKINGS KNEE HIGH (ALL) | 1 | $35.00 |
| TOURN CUFF 24 DUAL PORT/SING BLAD 24 | 1 | $150.00 |
| BANDAGE ESMARK 6 LATEX FREE | 1 | $65.00 |
| BOVIE ELECT HAND PENCIL | 1 | $22.00 |
| DRESSING SPONGE 4X4 STERILE | 2 | $6.00 |
| FIBERWIRE AR-7200 | 3 | $56.00 |
| GOWN STER W/TOWEL XL | 3 | $23.00 |
| IRRIG SOL NACL 1000 2F7124 | 1 | $7.00 |
| IV ADMIN SET PRIMARY | 1 | $64.00 |
| IV ADMIN SET SECONDARY | 1 | $24.00 |
| MASTISOL LIQUID ADHESIVE | 1 | $7.00 |
| PACK ARTHROSCOPY | 1 | $112.00 |
| SUT MONOCRYL 4-0 P-3 MCP494G | 1 | $14.50 |
| SUT VICRYL 2-0 CT-2 VCP269H | 3 | $8.00 |
| SUT VICRYL 3-0 PS-2 VCP427H | 1 | $16.00 |
| TRAY NERVE BLOCK CATH | 1 | $254.00 |
| TUBING SUCT 12 | 1 | $17.00 |
| YANKAUER SUCT W TUBE (A) | 1 | $17.00 |
| P14 COMP. METABOLIC PANEL (CMP) | 1 | $63.00 |
| PREGNANCY TEST URINE | 1 | $72.00 |
| CBC (with auto diff) | 1 | $48.00 |
| OPERATING ROOM 1 1/2 HR | 1 | $2426.00 |
| BUPIVACAINE (MARCAINE)0.25% INJ : 30ML | 1 | $24.00 |
| BUPIVACAINE LIPOSOME 1.3% INJ : 10ML | 1 | $525.50 |
| CEFAZOLIN (ANCEF) INJ : 1 GRAM VIAL | 3 | $20.00 |
| CEFAZOLIN/D5W : 2 | 1 | $99.25 |
| DEXAMETHASONE(DECADRON) INJ : 4MG/1ML | 1 | $20.00 |
| FENTANYL INJ : 50MCG/ML 2ML | 1 | $20.00 |
| KETOROLAC (TORADOL) INJ : 60MG/2ML | 1 | $20.00 |
| MIDAZOLAM INJ 2MG/2ML ANES | 1 | $20.00 |
| MIDAZOLAM INJ : 10MG/2ML(ANE | 1 | $20.00 |
| ROPIVACAINE 0.5%(NA | 1 | $77.00 |
| ZOFRAN INJ : 4MG/2ML | 1 | $20.00 |
| LIDOCAINE 2% INJ : 20MG/ML 5ML MPF | 1 | $20.00 |
| OXYCODONE HCL : 5MG TAB | 2 | $5.00 |
| SOD CITRATE/CITRIC | 1 | $12.00 |
| PACU 1 HR | 1 | $882.00 |
| Standard Itemized Estimate, Excluding Fees: | $8,159.00 |
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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