performed in setting:
 Inpatient |
Outpatient |
 Clinic |
Estimated Contracted Insurance Allowed Amount calculated with Aetna Worker Compensation
This service is not currently contracted with this insurance carrier.
*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 |
|---|---|---|---|
| $30,909.00 | $15,283.70 | $30,909.00 | This service is not currently contracted with this insurance carrier. |
Minimum Amount:
$15,283.70
$15,283.70
Maximum Amount:
$30,909.00
$30,909.00
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) |
|---|---|---|
| CHLORAPREP 3ML APPLICATOR | 1 | $13.00 |
| DERMABOND ADVANCED | 1 | $144.00 |
| DRAPE BRACHIAL ANGIOGRAPHY | 1 | $13.00 |
| DRESSING SPONGE 4X4 STERILE | 1 | $6.00 |
| GOWN STER W/TOWEL XL | 1 | $23.00 |
| INSERT PAT-ACTIVE HIT RECORDER (ILR) | 1 | $22113.00 |
| LIDOCAINE 1% INJ : 10MG/ML 20ML MDV | 1 | $20.00 |
| LOOP RECORDER SYSTEM | 1 | $8500.00 |
| PEN SURGICAL MARKIN | 1 | $0.00 |
| ROPIVACAINE 0.5%(NA | 1 | $77.00 |
| Standard Itemized Estimate, Excluding Fees: | $30,909.00 |
Potential Additional Fees
| Physician's Fee | Procedure not available with a member of our physicians group. Fee subject to vary.* |
| 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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