Cameron Memorial Community Hospital

All Charges

Charge

Type

Setting

Price

RALTEGRAVIR 400 MG ORAL TAB

Facility

$236.96

Service Code	NDC 00006022761
Hospital Charge Code	88608
Hospital Revenue Code	250
Min. Negotiated Rate	$177.72
Max. Negotiated Rate	$220.38
Rate for Payer: Aetna Commercial	$204.74
Rate for Payer: Cash Price	$146.92
Rate for Payer: Cigna All Commercial	$204.50
Rate for Payer: CORVEL All Commercial	$220.38
Rate for Payer: Coventry All Commercial	$208.53
Rate for Payer: Encore All Commercial	$218.13
Rate for Payer: Frontpath All Commercial	$218.01
Rate for Payer: Humana ChoiceCare	$204.67
Rate for Payer: Lutheran Preferred All Commercial	$213.27
Rate for Payer: PHCS All Commercial	$177.72
Rate for Payer: PHP All Commercial	$179.71
Rate for Payer: Sagamore Health Network All Products	$182.94
Rate for Payer: Signature Care EPO	$196.68
Rate for Payer: Signature Care PPO	$208.53
Rate for Payer: United Healthcare Commercial	$186.73

RANOLAZINE 500 MG ORAL TB12

Facility

$10.17

Service Code	NDC 60687054911
Hospital Charge Code	70434
Hospital Revenue Code	637
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$9.46
Rate for Payer: Aetna Commercial	$8.58
Rate for Payer: Aetna Medicare	$3.25
Rate for Payer: Anthem Blue Cross of IN Medicare	$3.15
Rate for Payer: Anthem Blue Cross of IN PPO/Pathway	$5.84
Rate for Payer: Anthem Blue Cross of IN Traditional	$6.36
Rate for Payer: CareSource Indiana of IN Just 4 Me	$3.74
Rate for Payer: CareSource Indiana of IN Medicare	$3.58
Rate for Payer: Cash Price	$6.31
Rate for Payer: Centivo All Commercial	$5.53
Rate for Payer: Cigna All Commercial	$8.78
Rate for Payer: CORVEL All Commercial	$9.46
Rate for Payer: Coventry All Commercial	$8.95
Rate for Payer: Encore All Commercial	$9.36
Rate for Payer: Frontpath All Commercial	$9.36
Rate for Payer: Humana ChoiceCare	$8.78
Rate for Payer: Humana Medicare	$3.25
Rate for Payer: Lucent All Commercial	$5.53
Rate for Payer: Lutheran Preferred All Commercial	$9.15
Rate for Payer: PHCS All Commercial	$7.63
Rate for Payer: PHP All Commercial	$7.71
Rate for Payer: Plain Church Group Ministry All Commercial	$3.97
Rate for Payer: Sagamore Health Network All Products	$7.85
Rate for Payer: Signature Care EPO	$8.44
Rate for Payer: Signature Care PPO	$8.95
Rate for Payer: Three Rivers Preferred All Commercial	$8.65
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Medicare	$3.25

RANOLAZINE 500 MG ORAL TB12

Facility

$10.17

Service Code	NDC 60687054921
Hospital Charge Code	70434
Hospital Revenue Code	637
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$9.46
Rate for Payer: Aetna Commercial	$8.58
Rate for Payer: Aetna Medicare	$3.25
Rate for Payer: Anthem Blue Cross of IN Medicare	$3.15
Rate for Payer: Anthem Blue Cross of IN PPO/Pathway	$5.84
Rate for Payer: Anthem Blue Cross of IN Traditional	$6.36
Rate for Payer: CareSource Indiana of IN Just 4 Me	$3.74
Rate for Payer: CareSource Indiana of IN Medicare	$3.58
Rate for Payer: Cash Price	$6.31
Rate for Payer: Centivo All Commercial	$5.53
Rate for Payer: Cigna All Commercial	$8.78
Rate for Payer: CORVEL All Commercial	$9.46
Rate for Payer: Coventry All Commercial	$8.95
Rate for Payer: Encore All Commercial	$9.36
Rate for Payer: Frontpath All Commercial	$9.36
Rate for Payer: Humana ChoiceCare	$8.78
Rate for Payer: Humana Medicare	$3.25
Rate for Payer: Lucent All Commercial	$5.53
Rate for Payer: Lutheran Preferred All Commercial	$9.15
Rate for Payer: PHCS All Commercial	$7.63
Rate for Payer: PHP All Commercial	$7.71
Rate for Payer: Plain Church Group Ministry All Commercial	$3.97
Rate for Payer: Sagamore Health Network All Products	$7.85
Rate for Payer: Signature Care EPO	$8.44
Rate for Payer: Signature Care PPO	$8.95
Rate for Payer: Three Rivers Preferred All Commercial	$8.65
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Medicare	$3.25

RANOLAZINE 500 MG ORAL TB12

Facility

$10.17

Service Code	NDC 60687054911
Hospital Charge Code	70434
Hospital Revenue Code	250
Min. Negotiated Rate	$7.63
Max. Negotiated Rate	$9.46
Rate for Payer: Aetna Commercial	$8.79
Rate for Payer: Cash Price	$6.31
Rate for Payer: Cigna All Commercial	$8.78
Rate for Payer: CORVEL All Commercial	$9.46
Rate for Payer: Coventry All Commercial	$8.95
Rate for Payer: Encore All Commercial	$9.36
Rate for Payer: Frontpath All Commercial	$9.36
Rate for Payer: Humana ChoiceCare	$8.78
Rate for Payer: Lutheran Preferred All Commercial	$9.15
Rate for Payer: PHCS All Commercial	$7.63
Rate for Payer: PHP All Commercial	$7.71
Rate for Payer: Sagamore Health Network All Products	$7.85
Rate for Payer: Signature Care EPO	$8.44
Rate for Payer: Signature Care PPO	$8.95
Rate for Payer: United Healthcare Commercial	$8.01

RANOLAZINE 500 MG ORAL TB12

Facility

$10.17

Service Code	NDC 60687054921
Hospital Charge Code	70434
Hospital Revenue Code	250
Min. Negotiated Rate	$7.63
Max. Negotiated Rate	$9.46
Rate for Payer: Aetna Commercial	$8.79
Rate for Payer: Cash Price	$6.31
Rate for Payer: Cigna All Commercial	$8.78
Rate for Payer: CORVEL All Commercial	$9.46
Rate for Payer: Coventry All Commercial	$8.95
Rate for Payer: Encore All Commercial	$9.36
Rate for Payer: Frontpath All Commercial	$9.36
Rate for Payer: Humana ChoiceCare	$8.78
Rate for Payer: Lutheran Preferred All Commercial	$9.15
Rate for Payer: PHCS All Commercial	$7.63
Rate for Payer: PHP All Commercial	$7.71
Rate for Payer: Sagamore Health Network All Products	$7.85
Rate for Payer: Signature Care EPO	$8.44
Rate for Payer: Signature Care PPO	$8.95
Rate for Payer: United Healthcare Commercial	$8.01

RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE)

Facility

$488.57

Service Code	CPT 27420
Hospital Revenue Code	360
Min. Negotiated Rate	$488.57
Max. Negotiated Rate	$488.57
Rate for Payer: Anthem Blue Cross of IN Medicaid	$488.57
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$488.57
Rate for Payer: Managed Health Services Medicaid	$488.57
Rate for Payer: MDWise Medicaid	$488.57

RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE)

Facility

$1,014.81

Service Code	CPT 27422
Hospital Revenue Code	360
Min. Negotiated Rate	$1,014.81
Max. Negotiated Rate	$1,014.81
Rate for Payer: Anthem Blue Cross of IN Medicaid	$1,014.81
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$1,014.81
Rate for Payer: Managed Health Services Medicaid	$1,014.81
Rate for Payer: MDWise Medicaid	$1,014.81

REGADENOSON 0.4 MG/5 ML IV SYRG

Facility

$1,123.70

Service Code	HCPCS J2785
Hospital Charge Code	91408
Hospital Revenue Code	636
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$1,045.04
Rate for Payer: Aetna Commercial	$948.40
Rate for Payer: Aetna Medicare	$359.58
Rate for Payer: Anthem Blue Cross of IN Medicaid	$2.29
Rate for Payer: Anthem Blue Cross of IN Medicare	$348.35
Rate for Payer: Anthem Blue Cross of IN PPO/Pathway	$645.34
Rate for Payer: Anthem Blue Cross of IN Traditional	$702.42
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$2.29
Rate for Payer: CareSource Indiana of IN Just 4 Me	$413.52
Rate for Payer: CareSource Indiana of IN Medicare	$395.54
Rate for Payer: Cash Price	$696.69
Rate for Payer: Cash Price	$696.69
Rate for Payer: Centivo All Commercial	$611.29
Rate for Payer: Cigna All Commercial	$969.75
Rate for Payer: CORVEL All Commercial	$1,045.04
Rate for Payer: Coventry All Commercial	$988.86
Rate for Payer: Encore All Commercial	$1,034.37
Rate for Payer: Frontpath All Commercial	$1,033.80
Rate for Payer: Humana ChoiceCare	$970.54
Rate for Payer: Humana Medicare	$359.58
Rate for Payer: Lucent All Commercial	$611.29
Rate for Payer: Lutheran Preferred All Commercial	$1,011.33
Rate for Payer: Managed Health Services Medicaid	$2.29
Rate for Payer: MDWise Medicaid	$2.29
Rate for Payer: PHCS All Commercial	$842.77
Rate for Payer: PHP All Commercial	$852.21
Rate for Payer: Plain Church Group Ministry All Commercial	$438.24
Rate for Payer: Sagamore Health Network All Products	$867.50
Rate for Payer: Signature Care EPO	$932.67
Rate for Payer: Signature Care PPO	$988.86
Rate for Payer: Three Rivers Preferred All Commercial	$955.14
Rate for Payer: United Healthcare Commercial	$885.48
Rate for Payer: United Healthcare Medicare	$359.58

REGADENOSON 0.4 MG/5 ML IV SYRG

Facility

$1,123.70

Service Code	HCPCS J2785
Hospital Charge Code	91408
Hospital Revenue Code	250
Min. Negotiated Rate	$842.77
Max. Negotiated Rate	$1,045.04
Rate for Payer: Aetna Commercial	$970.88
Rate for Payer: Cash Price	$696.69
Rate for Payer: Cigna All Commercial	$969.75
Rate for Payer: CORVEL All Commercial	$1,045.04
Rate for Payer: Coventry All Commercial	$988.86
Rate for Payer: Encore All Commercial	$1,034.37
Rate for Payer: Frontpath All Commercial	$1,033.80
Rate for Payer: Humana ChoiceCare	$970.54
Rate for Payer: Lutheran Preferred All Commercial	$1,011.33
Rate for Payer: PHCS All Commercial	$842.77
Rate for Payer: PHP All Commercial	$852.21
Rate for Payer: Sagamore Health Network All Products	$867.50
Rate for Payer: Signature Care EPO	$932.67
Rate for Payer: Signature Care PPO	$988.86
Rate for Payer: United Healthcare Commercial	$885.48

REHABILITATION

Facility

$9,380.43

Service Code	APR-DRG 8602
Min. Negotiated Rate	$667.00
Max. Negotiated Rate	$9,380.43
Rate for Payer: Anthem Blue Cross of IN Medicaid	$667.00
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$667.00
Rate for Payer: Managed Health Services Medicaid	$667.00
Rate for Payer: MDWise Medicaid	$667.00

REHABILITATION

Facility

$7,305.50

Service Code	APR-DRG 8601
Min. Negotiated Rate	$667.00
Max. Negotiated Rate	$7,305.50
Rate for Payer: Anthem Blue Cross of IN Medicaid	$667.00
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$667.00
Rate for Payer: Managed Health Services Medicaid	$667.00
Rate for Payer: MDWise Medicaid	$667.00

REHABILITATION

Facility

$9,466.89

Service Code	APR-DRG 8603
Min. Negotiated Rate	$667.00
Max. Negotiated Rate	$9,466.89
Rate for Payer: Anthem Blue Cross of IN Medicaid	$667.00
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$667.00
Rate for Payer: Managed Health Services Medicaid	$667.00
Rate for Payer: MDWise Medicaid	$667.00

REHABILITATION

Facility

$11,109.54

Service Code	APR-DRG 8604
Min. Negotiated Rate	$667.00
Max. Negotiated Rate	$11,109.54
Rate for Payer: Anthem Blue Cross of IN Medicaid	$667.00
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$667.00
Rate for Payer: Managed Health Services Medicaid	$667.00
Rate for Payer: MDWise Medicaid	$667.00

REMDESIVIR 100 MG IV SOLR

Facility

$2,539.40

Service Code	HCPCS J0248
Hospital Charge Code	191228
Hospital Revenue Code	250
Min. Negotiated Rate	$1,904.55
Max. Negotiated Rate	$2,361.64
Rate for Payer: Aetna Commercial	$2,194.04
Rate for Payer: Cash Price	$1,574.43
Rate for Payer: Cigna All Commercial	$2,191.50
Rate for Payer: CORVEL All Commercial	$2,361.64
Rate for Payer: Coventry All Commercial	$2,234.67
Rate for Payer: Encore All Commercial	$2,337.52
Rate for Payer: Frontpath All Commercial	$2,336.25
Rate for Payer: Humana ChoiceCare	$2,193.28
Rate for Payer: Lutheran Preferred All Commercial	$2,285.46
Rate for Payer: PHCS All Commercial	$1,904.55
Rate for Payer: PHP All Commercial	$1,925.88
Rate for Payer: Sagamore Health Network All Products	$1,960.42
Rate for Payer: Signature Care EPO	$2,107.70
Rate for Payer: Signature Care PPO	$2,234.67
Rate for Payer: United Healthcare Commercial	$2,001.05

REMDESIVIR 100 MG IV SOLR

Facility

$2,539.40

Service Code	HCPCS J0248
Hospital Charge Code	191228
Hospital Revenue Code	636
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$2,361.64
Rate for Payer: Aetna Commercial	$2,143.25
Rate for Payer: Aetna Medicare	$812.61
Rate for Payer: Anthem Blue Cross of IN Medicaid	$5.46
Rate for Payer: Anthem Blue Cross of IN Medicare	$787.21
Rate for Payer: Anthem Blue Cross of IN PPO/Pathway	$1,458.38
Rate for Payer: Anthem Blue Cross of IN Traditional	$1,587.38
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$5.46
Rate for Payer: CareSource Indiana of IN Just 4 Me	$934.50
Rate for Payer: CareSource Indiana of IN Medicare	$893.87
Rate for Payer: Cash Price	$1,574.43
Rate for Payer: Cash Price	$1,574.43
Rate for Payer: Centivo All Commercial	$1,381.43
Rate for Payer: Cigna All Commercial	$2,191.50
Rate for Payer: CORVEL All Commercial	$2,361.64
Rate for Payer: Coventry All Commercial	$2,234.67
Rate for Payer: Encore All Commercial	$2,337.52
Rate for Payer: Frontpath All Commercial	$2,336.25
Rate for Payer: Humana ChoiceCare	$2,193.28
Rate for Payer: Humana Medicare	$812.61
Rate for Payer: Lucent All Commercial	$1,381.43
Rate for Payer: Lutheran Preferred All Commercial	$2,285.46
Rate for Payer: Managed Health Services Medicaid	$5.46
Rate for Payer: MDWise Medicaid	$5.46
Rate for Payer: PHCS All Commercial	$1,904.55
Rate for Payer: PHP All Commercial	$1,925.88
Rate for Payer: Plain Church Group Ministry All Commercial	$990.37
Rate for Payer: Sagamore Health Network All Products	$1,960.42
Rate for Payer: Signature Care EPO	$2,107.70
Rate for Payer: Signature Care PPO	$2,234.67
Rate for Payer: Three Rivers Preferred All Commercial	$2,158.49
Rate for Payer: United Healthcare Commercial	$2,001.05
Rate for Payer: United Healthcare Medicare	$812.61

REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA

Facility

$1,014.81

Service Code	CPT 27372
Hospital Revenue Code	360
Min. Negotiated Rate	$1,014.81
Max. Negotiated Rate	$1,014.81
Rate for Payer: Anthem Blue Cross of IN Medicaid	$1,014.81
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$1,014.81
Rate for Payer: Managed Health Services Medicaid	$1,014.81
Rate for Payer: MDWise Medicaid	$1,014.81

REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR COMPLICATED

Facility

$488.57

Service Code	CPT 20525
Hospital Revenue Code	360
Min. Negotiated Rate	$488.57
Max. Negotiated Rate	$488.57
Rate for Payer: Anthem Blue Cross of IN Medicaid	$488.57
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$488.57
Rate for Payer: Managed Health Services Medicaid	$488.57
Rate for Payer: MDWise Medicaid	$488.57

REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM ANTERIOR CHAMBER OF EYE OR LENS

Facility

$443.28

Service Code	CPT 65235
Hospital Revenue Code	360
Min. Negotiated Rate	$443.28
Max. Negotiated Rate	$443.28
Rate for Payer: Anthem Blue Cross of IN Medicaid	$443.28
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$443.28
Rate for Payer: Managed Health Services Medicaid	$443.28
Rate for Payer: MDWise Medicaid	$443.28

REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS

Facility

$318.54

Service Code	CPT 24200
Hospital Revenue Code	360
Min. Negotiated Rate	$318.54
Max. Negotiated Rate	$318.54
Rate for Payer: Anthem Blue Cross of IN Medicaid	$318.54
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$318.54
Rate for Payer: Managed Health Services Medicaid	$318.54
Rate for Payer: MDWise Medicaid	$318.54

REMOVAL OF PROSTHESIS, INCLUDES DEBRIDEMENT AND SYNOVECTOMY WHEN PERFORMED; HUMERAL AND GLENOID COMPONENTS (EG, TOTAL SHOULDER)

Facility

$2,226.60

Service Code	CPT 23335
Hospital Revenue Code	360
Min. Negotiated Rate	$2,226.60
Max. Negotiated Rate	$2,226.60
Rate for Payer: Anthem Blue Cross of IN Medicaid	$2,226.60
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$2,226.60
Rate for Payer: Managed Health Services Medicaid	$2,226.60
Rate for Payer: MDWise Medicaid	$2,226.60

REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM

Facility

$488.57

Service Code	CPT 13132
Hospital Revenue Code	360
Min. Negotiated Rate	$488.57
Max. Negotiated Rate	$488.57
Rate for Payer: Anthem Blue Cross of IN Medicaid	$488.57
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$488.57
Rate for Payer: Managed Health Services Medicaid	$488.57
Rate for Payer: MDWise Medicaid	$488.57

REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM

Facility

$488.57

Service Code	CPT 13121
Hospital Revenue Code	360
Min. Negotiated Rate	$488.57
Max. Negotiated Rate	$488.57
Rate for Payer: Anthem Blue Cross of IN Medicaid	$488.57
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$488.57
Rate for Payer: Managed Health Services Medicaid	$488.57
Rate for Payer: MDWise Medicaid	$488.57

REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$488.57

Service Code	CPT 13122
Hospital Revenue Code	360
Min. Negotiated Rate	$488.57
Max. Negotiated Rate	$488.57
Rate for Payer: Anthem Blue Cross of IN Medicaid	$488.57
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$488.57
Rate for Payer: Managed Health Services Medicaid	$488.57
Rate for Payer: MDWise Medicaid	$488.57

REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM

Facility

$488.57

Service Code	CPT 13101
Hospital Revenue Code	360
Min. Negotiated Rate	$488.57
Max. Negotiated Rate	$488.57
Rate for Payer: Anthem Blue Cross of IN Medicaid	$488.57
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$488.57
Rate for Payer: Managed Health Services Medicaid	$488.57
Rate for Payer: MDWise Medicaid	$488.57

REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$488.57

Service Code	CPT 13102
Hospital Revenue Code	360
Min. Negotiated Rate	$488.57
Max. Negotiated Rate	$488.57
Rate for Payer: Anthem Blue Cross of IN Medicaid	$488.57
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP	$488.57
Rate for Payer: Managed Health Services Medicaid	$488.57
Rate for Payer: MDWise Medicaid	$488.57

Know your out-of-pocket cost for care.

All Charges