Cameron Memorial Community Hospital

All Charges

Charge

Type

Price

Excision of pilonidal cyst or sinus; extensive

Facility OP

$1,905.42

Service Code	CPT 11771
Hospital Charge Code	CPT-11771
Hospital Revenue Code	360
Min. Negotiated Rate	$1,905.42
Max. Negotiated Rate	$1,905.42
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,905.42
Rate for Payer: Managed Health Services Medicaid	$1,905.42
Rate for Payer: MDWise Medicaid	$1,905.42

Excision or curettage of bone cyst or benign tumor of carpal bones;

Facility OP

$1,905.42

Service Code	CPT 25130
Hospital Charge Code	CPT-25130
Hospital Revenue Code	360
Min. Negotiated Rate	$1,905.42
Max. Negotiated Rate	$1,905.42
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,905.42
Rate for Payer: Managed Health Services Medicaid	$1,905.42
Rate for Payer: MDWise Medicaid	$1,905.42

Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process;

Facility OP

$1,905.42

Service Code	CPT 24120
Hospital Charge Code	CPT-24120
Hospital Revenue Code	360
Min. Negotiated Rate	$1,905.42
Max. Negotiated Rate	$1,905.42
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,905.42
Rate for Payer: Managed Health Services Medicaid	$1,905.42
Rate for Payer: MDWise Medicaid	$1,905.42

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less

Facility OP

$381.15

Service Code	CPT 11440
Hospital Charge Code	CPT-11440
Hospital Revenue Code	360
Min. Negotiated Rate	$381.15
Max. Negotiated Rate	$381.15
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$381.15
Rate for Payer: Managed Health Services Medicaid	$381.15
Rate for Payer: MDWise Medicaid	$381.15

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm

Facility OP

$648.18

Service Code	CPT 11441
Hospital Charge Code	CPT-11441
Hospital Revenue Code	360
Min. Negotiated Rate	$648.18
Max. Negotiated Rate	$648.18
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$648.18
Rate for Payer: Managed Health Services Medicaid	$648.18
Rate for Payer: MDWise Medicaid	$648.18

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm

Facility OP

$648.18

Service Code	CPT 11442
Hospital Charge Code	CPT-11442
Hospital Revenue Code	360
Min. Negotiated Rate	$648.18
Max. Negotiated Rate	$648.18
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$648.18
Rate for Payer: Managed Health Services Medicaid	$648.18
Rate for Payer: MDWise Medicaid	$648.18

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm

Facility OP

$1,044.85

Service Code	CPT 11443
Hospital Charge Code	CPT-11443
Hospital Revenue Code	360
Min. Negotiated Rate	$1,044.85
Max. Negotiated Rate	$1,044.85
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,044.85
Rate for Payer: Managed Health Services Medicaid	$1,044.85
Rate for Payer: MDWise Medicaid	$1,044.85

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm

Facility OP

$1,242.31

Service Code	CPT 11444
Hospital Charge Code	CPT-11444
Hospital Revenue Code	360
Min. Negotiated Rate	$1,242.31
Max. Negotiated Rate	$1,242.31
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,242.31
Rate for Payer: Managed Health Services Medicaid	$1,242.31
Rate for Payer: MDWise Medicaid	$1,242.31

Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater

Facility OP

$2,273.62

Service Code	CPT 22903
Hospital Charge Code	CPT-22903
Hospital Revenue Code	360
Min. Negotiated Rate	$2,273.62
Max. Negotiated Rate	$2,273.62
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$2,273.62
Rate for Payer: Managed Health Services Medicaid	$2,273.62
Rate for Payer: MDWise Medicaid	$2,273.62

Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater

Facility OP

$1,728.79

Service Code	CPT 21931
Hospital Charge Code	CPT-21931
Hospital Revenue Code	360
Min. Negotiated Rate	$1,728.79
Max. Negotiated Rate	$1,728.79
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,728.79
Rate for Payer: Managed Health Services Medicaid	$1,728.79
Rate for Payer: MDWise Medicaid	$1,728.79

Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater

Facility OP

$1,728.79

Service Code	CPT 21933
Hospital Charge Code	CPT-21933
Hospital Revenue Code	360
Min. Negotiated Rate	$1,728.79
Max. Negotiated Rate	$1,728.79
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,728.79
Rate for Payer: Managed Health Services Medicaid	$1,728.79
Rate for Payer: MDWise Medicaid	$1,728.79

Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater

Facility OP

$1,728.79

Service Code	CPT 21012
Hospital Charge Code	CPT-21012
Hospital Revenue Code	360
Min. Negotiated Rate	$1,728.79
Max. Negotiated Rate	$1,728.79
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,728.79
Rate for Payer: Managed Health Services Medicaid	$1,728.79
Rate for Payer: MDWise Medicaid	$1,728.79

Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater

Facility OP

$1,242.31

Service Code	CPT 21552
Hospital Charge Code	CPT-21552
Hospital Revenue Code	360
Min. Negotiated Rate	$1,242.31
Max. Negotiated Rate	$1,242.31
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,242.31
Rate for Payer: Managed Health Services Medicaid	$1,242.31
Rate for Payer: MDWise Medicaid	$1,242.31

Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greater

Facility OP

$1,728.79

Service Code	CPT 23073
Hospital Charge Code	CPT-23073
Hospital Revenue Code	360
Min. Negotiated Rate	$1,728.79
Max. Negotiated Rate	$1,728.79
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,728.79
Rate for Payer: Managed Health Services Medicaid	$1,728.79
Rate for Payer: MDWise Medicaid	$1,728.79

Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater

Facility OP

$1,728.79

Service Code	CPT 24071
Hospital Charge Code	CPT-24071
Hospital Revenue Code	360
Min. Negotiated Rate	$1,728.79
Max. Negotiated Rate	$1,728.79
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$1,728.79
Rate for Payer: Managed Health Services Medicaid	$1,728.79
Rate for Payer: MDWise Medicaid	$1,728.79

Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more

Facility OP

$13,051.74

Service Code	CPT 66989
Hospital Charge Code	CPT-66989
Hospital Revenue Code	360
Min. Negotiated Rate	$13,051.74
Max. Negotiated Rate	$13,051.74
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$13,051.74
Rate for Payer: Managed Health Services Medicaid	$13,051.74
Rate for Payer: MDWise Medicaid	$13,051.74

Facility OP

$4,315.74

Service Code	CPT 66982
Hospital Charge Code	CPT-66982
Hospital Revenue Code	360
Min. Negotiated Rate	$4,315.74
Max. Negotiated Rate	$4,315.74
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$4,315.74
Rate for Payer: Managed Health Services Medicaid	$4,315.74
Rate for Payer: MDWise Medicaid	$4,315.74

Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with insertion of intraocular (eg, trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more

Facility OP

$13,051.74

Service Code	CPT 66991
Hospital Charge Code	CPT-66991
Hospital Revenue Code	360
Min. Negotiated Rate	$13,051.74
Max. Negotiated Rate	$13,051.74
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$13,051.74
Rate for Payer: Managed Health Services Medicaid	$13,051.74
Rate for Payer: MDWise Medicaid	$13,051.74

Facility OP

$4,315.74

Service Code	CPT 66984
Hospital Charge Code	CPT-66984
Hospital Revenue Code	360
Min. Negotiated Rate	$4,315.74
Max. Negotiated Rate	$4,315.74
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise	$4,315.74
Rate for Payer: Managed Health Services Medicaid	$4,315.74
Rate for Payer: MDWise Medicaid	$4,315.74

EZETIMIBE 10 MG ORAL TAB

Facility OP

$31.49

Service Code	NDC 50268029812
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$10.39
Max. Negotiated Rate	$29.29
Rate for Payer: Aetna Commercial	$26.58
Rate for Payer: Aetna Medicare	$10.39
Rate for Payer: Anthem Blue Cross of IN Medicare	$10.39
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange	$18.09
Rate for Payer: Anthem Blue Cross of IN Traditional	$19.69
Rate for Payer: CareSource Indiana of IN Just 4 Me	$11.95
Rate for Payer: CareSource Indiana of IN Medicare	$11.43
Rate for Payer: Cash Price	$19.53
Rate for Payer: Centivo All Commercial	$16.06
Rate for Payer: Cigna All Commercial	$27.18
Rate for Payer: CORVEL All Commercial	$29.29
Rate for Payer: Coventry All Commercial	$27.71
Rate for Payer: Encore All Commercial	$28.99
Rate for Payer: Frontpath All Commercial	$28.97
Rate for Payer: Humana ChoiceCare	$27.20
Rate for Payer: Humana Medicare	$16.06
Rate for Payer: Lucent All Commercial	$16.06
Rate for Payer: Lutheran Preferred All Commercial	$28.34
Rate for Payer: PHCS All Commercial	$23.62
Rate for Payer: PHP All Commercial	$23.88
Rate for Payer: Plain Church Group Ministry All Commercial	$12.28
Rate for Payer: Sagamore Health Network All Products	$24.31
Rate for Payer: Signature Care EPO	$26.14
Rate for Payer: Signature Care PPO	$27.71
Rate for Payer: Three Rivers Preferred All Commercial	$26.77
Rate for Payer: United Healthcare Commercial	$24.82
Rate for Payer: United Healthcare Medicare	$10.39

EZETIMIBE 10 MG ORAL TAB

Facility IP

$31.49

Service Code	NDC 50268029812
Hospital Charge Code	34153
Hospital Revenue Code	250
Min. Negotiated Rate	$23.62
Max. Negotiated Rate	$29.29
Rate for Payer: Aetna Commercial	$27.21
Rate for Payer: Cash Price	$19.53
Rate for Payer: Cigna All Commercial	$27.18
Rate for Payer: CORVEL All Commercial	$29.29
Rate for Payer: Coventry All Commercial	$27.71
Rate for Payer: Encore All Commercial	$28.99
Rate for Payer: Frontpath All Commercial	$28.97
Rate for Payer: Humana ChoiceCare	$27.20
Rate for Payer: Lutheran Preferred All Commercial	$28.34
Rate for Payer: PHCS All Commercial	$23.62
Rate for Payer: PHP All Commercial	$23.88
Rate for Payer: Sagamore Health Network All Products	$24.31
Rate for Payer: Signature Care EPO	$26.14
Rate for Payer: Signature Care PPO	$27.71
Rate for Payer: United Healthcare Commercial	$24.82

FAMOTIDINE 10 MG/ML IV SOLN

Facility IP

$18.00

Service Code	HCPCS J3490
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$16.74
Rate for Payer: Aetna Commercial	$15.55
Rate for Payer: Cash Price	$11.16
Rate for Payer: Cigna All Commercial	$15.53
Rate for Payer: CORVEL All Commercial	$16.74
Rate for Payer: Coventry All Commercial	$15.84
Rate for Payer: Encore All Commercial	$16.57
Rate for Payer: Frontpath All Commercial	$16.56
Rate for Payer: Humana ChoiceCare	$15.55
Rate for Payer: Lutheran Preferred All Commercial	$16.20
Rate for Payer: PHCS All Commercial	$13.50
Rate for Payer: PHP All Commercial	$13.65
Rate for Payer: Sagamore Health Network All Products	$13.90
Rate for Payer: Signature Care EPO	$14.94
Rate for Payer: Signature Care PPO	$15.84
Rate for Payer: United Healthcare Commercial	$14.18

FAMOTIDINE 10 MG/ML IV SOLN

Facility OP

$18.00

Service Code	HCPCS J3490
Hospital Charge Code	10009
Hospital Revenue Code	636
Min. Negotiated Rate	$5.94
Max. Negotiated Rate	$16.74
Rate for Payer: Aetna Commercial	$15.19
Rate for Payer: Aetna Medicare	$5.94
Rate for Payer: Anthem Blue Cross of IN Medicare	$5.94
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange	$10.34
Rate for Payer: Anthem Blue Cross of IN Traditional	$11.25
Rate for Payer: CareSource Indiana of IN Just 4 Me	$6.83
Rate for Payer: CareSource Indiana of IN Medicare	$6.53
Rate for Payer: Cash Price	$11.16
Rate for Payer: Centivo All Commercial	$9.18
Rate for Payer: Cigna All Commercial	$15.53
Rate for Payer: CORVEL All Commercial	$16.74
Rate for Payer: Coventry All Commercial	$15.84
Rate for Payer: Encore All Commercial	$16.57
Rate for Payer: Frontpath All Commercial	$16.56
Rate for Payer: Humana ChoiceCare	$15.55
Rate for Payer: Humana Medicare	$9.18
Rate for Payer: Lucent All Commercial	$9.18
Rate for Payer: Lutheran Preferred All Commercial	$16.20
Rate for Payer: PHCS All Commercial	$13.50
Rate for Payer: PHP All Commercial	$13.65
Rate for Payer: Plain Church Group Ministry All Commercial	$7.02
Rate for Payer: Sagamore Health Network All Products	$13.90
Rate for Payer: Signature Care EPO	$14.94
Rate for Payer: Signature Care PPO	$15.84
Rate for Payer: Three Rivers Preferred All Commercial	$15.30
Rate for Payer: United Healthcare Commercial	$14.18
Rate for Payer: United Healthcare Medicare	$5.94

FAMOTIDINE 20 MG ORAL TAB

Facility OP

$1.00

Service Code	NDC 00904719361
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna Commercial	$0.84
Rate for Payer: Aetna Medicare	$0.33
Rate for Payer: Anthem Blue Cross of IN Medicare	$0.33
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange	$0.57
Rate for Payer: Anthem Blue Cross of IN Traditional	$0.63
Rate for Payer: CareSource Indiana of IN Just 4 Me	$0.38
Rate for Payer: CareSource Indiana of IN Medicare	$0.36
Rate for Payer: Cash Price	$0.62
Rate for Payer: Centivo All Commercial	$0.51
Rate for Payer: Cigna All Commercial	$0.86
Rate for Payer: CORVEL All Commercial	$0.93
Rate for Payer: Coventry All Commercial	$0.88
Rate for Payer: Encore All Commercial	$0.92
Rate for Payer: Frontpath All Commercial	$0.92
Rate for Payer: Humana ChoiceCare	$0.86
Rate for Payer: Humana Medicare	$0.51
Rate for Payer: Lucent All Commercial	$0.51
Rate for Payer: Lutheran Preferred All Commercial	$0.90
Rate for Payer: PHCS All Commercial	$0.75
Rate for Payer: PHP All Commercial	$0.76
Rate for Payer: Plain Church Group Ministry All Commercial	$0.39
Rate for Payer: Sagamore Health Network All Products	$0.77
Rate for Payer: Signature Care EPO	$0.83
Rate for Payer: Signature Care PPO	$0.88
Rate for Payer: Three Rivers Preferred All Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$0.79
Rate for Payer: United Healthcare Medicare	$0.33

FAMOTIDINE 20 MG ORAL TAB

Facility IP

$1.00

Service Code	NDC 00904719361
Hospital Charge Code	10011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna Commercial	$0.86
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna All Commercial	$0.86
Rate for Payer: CORVEL All Commercial	$0.93
Rate for Payer: Coventry All Commercial	$0.88
Rate for Payer: Encore All Commercial	$0.92
Rate for Payer: Frontpath All Commercial	$0.92
Rate for Payer: Humana ChoiceCare	$0.86
Rate for Payer: Lutheran Preferred All Commercial	$0.90
Rate for Payer: PHCS All Commercial	$0.75
Rate for Payer: PHP All Commercial	$0.76
Rate for Payer: Sagamore Health Network All Products	$0.77
Rate for Payer: Signature Care EPO	$0.83
Rate for Payer: Signature Care PPO	$0.88
Rate for Payer: United Healthcare Commercial	$0.79

Price Transparency.

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