Whether you're a patient or caregiver, we've made it easier for members with a PPO plan to make decisions about your health care costs with the Treatment Cost Estimator. Use this tool to research estimated cost ranges for various health care services, including high-cost or elective services. You can also use the tool to research the differences in the estimated costs of a particular service based on the facility where the services are provided, such as a doctor's office, hospital, imaging center or ambulatory surgery center. We get these estimates exclusively from 12 months of PPO health benefit claims data. Your out-of-pocket costs will differ, based on your specific benefit and coverage information, as well as the specific services you receive.
The information provided by this tool is not a guarantee of coverage, a guarantee of payment or an authorization for a particular service. The estimates provided by this tool are not an exact calculation of your actual costs and do not reflect all of the terms, conditions, limitations and exclusions that may apply to your coverage. Your actual costs will vary depending upon the specifics of your benefit plan and the particular services and supplies you receive.
The Treatment Cost Estimator is intended to be a reference tool and is not a substitute for medical decision-making. Your health is an important priority, so do not avoid getting health care based on the cost estimates on this website. Use this information when you talk to your provider or physician, only you and your doctor can decide which medical decision is best for you. Be sure to consult with your own physician about your particular medical condition and discuss treatment and facility options. The information in the tool is not a recommendation or endorsement of any particular health care facility or its services and doesn't guarantee services will be available or will be of any particular quality or cost.
Costs for the same health care service can vary a great deal by location and health care provider; the Treatment Cost Estimator can help you stretch your health care dollars by allowing you to compare what it may cost to have your desired service performed at various facilities.
The information available within this tool is developed using 12 months of PPO health benefit claims data, and provides members with an estimate of the range of costs for a specific health care service at a specific facility before your benefits are applied. For example, the typical cost for a knee replacement may range from around $11,000 to $13,000 at one facility, and may range from around $36,000 to $40,000 at another facility.
The range of costs reported by the tool represents only the typical costs for services supplied by facilities and professional health care providers (e.g., physicians) that are related to the primary health care service you selected. In addition, there may be costs for other services provided in addition to the primary medical treatment that are not reflected in the cost estimate, such as medications, lab tests, x-rays, etc., as well as additional costs for related services received at other facilities. In some cases these additional costs can be high, and you could be responsible for those costs depending on your benefit plan. Your actual costs will vary based on the specific services you receive, your benefits for that health care service and your progress towards meeting your annual deductible and copay maximum.
What's Not Included in the Typical Costs Estimate
Estimates do not take into account certain types of claims and services, such as:
Claims paid after a primary health plan has paid (secondary coverage)
Emergency cases, transplant cases
Claims that include numerous complications
Your specific benefit and coverage information
In addition, typical cost ranges for hospitals and facilities that do not have enough claims information for your selected health care service are excluded from the results.
The information about the facilities presented in this tool is for reference only and may have changed since this tool was last updated. Be sure to confirm with the facility the facility's address, phone number, specialty, and participation (in-network) status before making an appointment.
If you find that a particular facility is not listed for a certain type of health care service, it may be that the facility is not a participating provider in the Blue Shield network, that we do not have enough claims information to be able to provide a useful estimate of the cost of the selected health care service at such facility and/or the that the facility does not provide the service.
Most health care services involve a particular bundle of related services, tests and visits. We've developed a standard bundle that's typical for this service based on averages from 12 months of PPO health benefit claims data. Each cost range includes the typical cost range for this type of care's standard bundle of related services including facility, physician and other services, such as typical lab tests and x-rays. This gives you the total estimated cost of the standard bundle of service. Whether your estimate falls within the range depends on which of these related services your doctor recommends or prescribes for your care, your own condition, as well as your benefits. Remember, the costs displayed are estimates and your actual cost will vary. Health care services listed in the tool were selected because they are not emergency services and can be performed by a variety of health providers, allowing you to 'shop' for your health care in advance.
The information available in the tool is developed using 12 months of PPO health benefit claims data. Some providers may not be displayed because Blue Shield does not have enough claims information from a particular facility for a particular health care service.
If you find that a particular provider is not listed for a certain type of health care service, you may contact your provider directly about typical cost ranges for your service of interest.
The Treatment Cost Estimator uses your current overall medical spending to estimate your out-of-pocket cost.
Pending claims that have not yet been processed by Blue Shield are not included in your overall medical spend. Once these claims are processed, your balance towards deductible and out-of-pocket maximum may change. Your actual out-of-pocket cost may change from those estimated in the tool.
If your benefits include service type specific deductibles or limits (e.g. for chiropractic or acupuncture), your actual out-of-pocket cost may be different from the one in the Treatment Cost Estimator.
Your final out-of-pocket cost may be influenced by many other factors such as the mix of services, past performed services to a specific category, and other factors affecting individual treatments.
Individual facilities or health care providers may disagree with the methodology used to define the cost ranges, the cost data or quality measures. Many factors may influence cost or quality, including, but not limited to, the cost of uninsured and charity care, the type and severity of procedures, the case mix of a facility, special services such as trauma centers, burn units, medical and other educational programs, research, transplant services, technology, payer mix, and other factors affecting individual facilities and health care providers.
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