Blue Cross Community MMAI/Dual Eligible: disclosed hospital rates

iDirect answer

Based on the published hospital price files, Blue Cross Community MMAI/Dual Eligible appears in disclosed negotiated rates across 1 hospital and 55 services. This is public hospital price transparency data, not a guaranteed estimate of your bill.

Actual patient responsibility may vary based on your insurance plan, deductible, coinsurance, network status, diagnosis, setting, bundled services, clinical circumstances, and hospital billing practices.

55 prices shown.

Service	Hospital	Code	List price	Cash price	Negotiated range	Allowed (median)
13533-0800-20 - immune globulin intravenous and su Outpatient	Springfield Memorial Hospital	J1561 HCPCS	$3,839	$3,839	$1,583 – $1,583	—
55566-2300-00 - desmopressin 4 mcg/mL Inj Outpatient	Springfield Memorial Hospital	J2597 HCPCS	$195	$195	$145 – $145	—
61364-0181-03 - peramivir 10 mg/mL 20mL vial Outpatient	Springfield Memorial Hospital	J2547 HCPCS	$1,267	$1,267	$1,583 – $1,583	—
63323-0593-03 - glucagon 1 mg Inj Outpatient	Springfield Memorial Hospital	J1611 HCPCS	$451	$451	$145 – $145	—
66220-0160-10 - conivaptan 20 mg/100 mL-D5 Sol Outpatient	Springfield Memorial Hospital	C9488 HCPCS	$4,051	$4,051	$570 – $582	—
67919-0030-01 - ceftolozane-tazobactam 1 g-0.5 g P Outpatient	Springfield Memorial Hospital	J0695 HCPCS	$638	$638	$145 – $145	—
BASEPLATE HA ADAPTER 25MM Outpatient	Springfield Memorial Hospital	C1776 HCPCS	$12,938	$12,938	$1,560 – $1,591	—
BEARING HUMRL XL 44-36 STD Outpatient	Springfield Memorial Hospital	C1776 HCPCS	$6,300	$6,300	$349 – $356	—
Bill Only Opiates Serum /Plasma Outpatient	Springfield Memorial Hospital	80361 CPT	$246	$246	$14.24 – $14.24	—
BONE CORPECTOMY FIB 50MM Outpatient	Springfield Memorial Hospital	C1713 HCPCS	$8,607	$8,607	$770 – $785	—
FMS-Amniocentesis Dx Outpatient	Springfield Memorial Hospital	59000 CPT	$1,813	$1,813	$699 – $3,474	—
FMS-EST PT Visit Only Lvl I Outpatient	Springfield Memorial Hospital	99211 CPT	$249	$249	$220 – $224	—
FMS-EST PT Visit Only Lvl II Outpatient	Springfield Memorial Hospital	99212 CPT	$288	$288	$220 – $224	—
FMS-EST PT Visit Only Lvl III Outpatient	Springfield Memorial Hospital	99213 CPT	$311	$311	$220 – $224	—
FMS-EST PT Visit Only Lvl IV Outpatient	Springfield Memorial Hospital	99214 CPT	$338	$338	$220 – $224	—
FMS-EST PT Visit Only Lvl V Outpatient	Springfield Memorial Hospital	99215 CPT	$361	$361	$220 – $224	—
FMS-Insertion of IUD Outpatient	Springfield Memorial Hospital	58300 CPT	$443	$443	$265 – $270	—
FMS-New PT Visit Only Lvl II Outpatient	Springfield Memorial Hospital	99202 CPT	$336	$336	$220 – $224	—
FMS-New PT Visit Only Lvl III Outpatient	Springfield Memorial Hospital	99203 CPT	$359	$359	$220 – $224	—
FMS-New PT Visit Only Lvl IV Outpatient	Springfield Memorial Hospital	99204 CPT	$384	$384	$220 – $224	—
FMS-New PT Visit Only Lvl V Outpatient	Springfield Memorial Hospital	99205 CPT	$407	$407	$220 – $224	—
GLENOSPHERE STANDARD 36MM Outpatient	Springfield Memorial Hospital	C1776 HCPCS	$9,000	$9,000	$842 – $858	—
HUMERAL BEARING/POLY XL 44-36-STD 3 Outpatient	Springfield Memorial Hospital	C1776 HCPCS	$6,300	$6,300	$349 – $356	—
IMPLANT PEEK CRV 14X11X6MM Outpatient	Springfield Memorial Hospital	C1713 HCPCS	$7,533	$7,533	$574 – $586	—
IMPLANT PEEK CRV 14X11X7MM Outpatient	Springfield Memorial Hospital	C1713 HCPCS	$7,533	$7,533	$574 – $586	—