Independence Blue Cross/Personal Choice: disclosed hospital rates

iDirect answer

Based on the published hospital price files, Independence Blue Cross/Personal Choice appears in disclosed negotiated rates across 2 hospitals and 101 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.

101 prices shown.

Service	Hospital	Code	List price	Cash price	Negotiated range	Allowed (median)
ALTEPLASE (TPA) 1 MG/ML SYRINGE EVD CLEARANCE Outpatient	Pennsylvania Hospital	J2997 HCPCS	$255	$255	$44.83 – $255	—
ALTEPLASE (TPA) INJECTION 1MG/ML ORD Outpatient	Pennsylvania Hospital	J2997 HCPCS	$308	$308	$54.15 – $308	—
ALTEPLASE (TPA) INJECTION 5MG/5ML ORD Outpatient	Pennsylvania Hospital	J2997 HCPCS	$1,372	$1,372	$91.48 – $1,372	—
ALTEPLASE TPA 1 MG ML SYRINGE EVD CLEARANCE Outpatient	The Hospital of the University of Pennsylvania	J2997 HCPCS	$255	$255	$44.83 – $255	—
AMINOCAPROIC ACID IVPB 10G 100ML NSS CNR Outpatient	The Hospital of the University of Pennsylvania	J0290 HCPCS	$75.00	$75.00	$0.49 – $75.00	—
AMPHOTERICIN B 100 MCG/ML NASAL IRRIGATION ORD Outpatient	Pennsylvania Hospital	J0285 HCPCS	$28.00	$28.00	$3.78 – $96.37	—
AMPICILLIN IVPB 1G/50ML NSS (CNR) Outpatient	Pennsylvania Hospital	J0290 HCPCS	$31.00	$31.00	$0.49 – $31.00	—
AMPICILLIN IVPB 2G/100ML NSS (CNR) Outpatient	Pennsylvania Hospital	J0290 HCPCS	$56.00	$56.00	$0.49 – $56.00	—
ATROPINE SULFATE 0.4 MG/ML INJECTION SOLN (WRAPPER Outpatient	Pennsylvania Hospital	J0461 HCPCS	$32.00	$32.00	$0.07 – $32.00	—
BETAMETHASONE SOD PHOS ACET 6 (33) MG/ML INJECTI Outpatient	Pennsylvania Hospital	J0702 HCPCS	$48.00	$48.00	$6.48 – $48.00	—
BUPIVACAINE 0 05 FENTANYL 2 MCG ML EPIDURAL 250 Outpatient	The Hospital of the University of Pennsylvania	102157 CDM	$52.00	$52.00	$5.82 – $52.00	—
BUPIVACAINE 0 1 EPIDURAL 250ML NSS CNR Outpatient	The Hospital of the University of Pennsylvania	102168 CDM	$33.00	$33.00	$3.70 – $33.00	—
CEFAZOLIN 100 MG ML ANESTHESIA PPMC Outpatient	The Hospital of the University of Pennsylvania	J0690 HCPCS	$2.00	$2.00	$0.22 – $2.00	—
CEFAZOLIN 100 MG/ML (ANESTHESIA) Outpatient	Pennsylvania Hospital	J0690 HCPCS	$2.00	$2.00	$0.27 – $2.00	—
CEFAZOLIN FORTE 50 MG/ML OPHTH SOLN ORD Outpatient	Pennsylvania Hospital	J0690 HCPCS	$89.00	$89.00	$0.81 – $89.00	—
CEFAZOLIN SODIUM 1 G INJECTION SOLR Outpatient	Pennsylvania Hospital	J0690 HCPCS	$23.00	$23.00	$0.81 – $23.00	—
CEFTAZIDIME 50 MG/ML OPHTH SOLN ORD Outpatient	Pennsylvania Hospital	J0713 HCPCS	$183	$183	$1.47 – $183	—
CIDOFOVIR 15 MG ML IV SOLN Outpatient	The Hospital of the University of Pennsylvania	J0740 HCPCS	$533	$533	$93.70 – $1,213	—
CIDOFOVIR 15 MG/ML IV SOLN Outpatient	Pennsylvania Hospital	J0740 HCPCS	$533	$533	$93.70 – $1,213	—
CLOG ZAPPER Outpatient	The Hospital of the University of Pennsylvania	100450 CDM	$86.00	$86.00	$9.63 – $86.00	—
CLONIDINE 0 01 MG ML ORAL SUSP ORD Outpatient	The Hospital of the University of Pennsylvania	17306 CDM	$71.00	$71.00	$7.95 – $71.00	—
CNR TAC 7 TOP SOLN REPACKAGE PHASE II 5 ML Outpatient	The Hospital of the University of Pennsylvania	99 CDM	$615	$615	$68.88 – $615	—
COAPTITE IMPLANT INJECTION Outpatient	The Hospital of the University of Pennsylvania	102005 CDM	$30.00	$30.00	$3.36 – $30.00	—
DEXAMETHASONE 0.25 MG PO SPLIT TABLET Outpatient	Pennsylvania Hospital	J8540 HCPCS	$1.00	$1.00	$0.01 – $1.00	—
DEXAMETHASONE IVPB 10MG 50ML NSS CNR Outpatient	The Hospital of the University of Pennsylvania	J1100 HCPCS	$23.00	$23.00	$0.09 – $23.00	—