Cameron Memorial Community Hospital

All Charges

Charge

Type

Price

OUTPATIENT EAPG 00879: PREVENTIVE OR SCREENING ENCOUNTER

Facility OP

$70.27

Service Code	EAPG 00879
Hospital Charge Code	EAPG 00879
Min. Negotiated Rate	$70.27
Max. Negotiated Rate	$70.27
Rate for Payer: Buckeye Health Medicaid OOS	$70.27
Rate for Payer: Molina Healthcare of OH Medicare	$70.27

OUTPATIENT EAPG 00880: HIV INFECTION

Facility OP

$128.76

Service Code	EAPG 00880
Hospital Charge Code	EAPG 00880
Min. Negotiated Rate	$128.76
Max. Negotiated Rate	$128.76
Rate for Payer: Buckeye Health Medicaid OOS	$128.76
Rate for Payer: Molina Healthcare of OH Medicare	$128.76

OUTPATIENT EAPG 00881: AIDS

Facility OP

$100.91

Service Code	EAPG 00881
Hospital Charge Code	EAPG 00881
Min. Negotiated Rate	$100.91
Max. Negotiated Rate	$100.91
Rate for Payer: Buckeye Health Medicaid OOS	$100.91
Rate for Payer: Molina Healthcare of OH Medicare	$100.91

OUTPATIENT EAPG 00882: GENETIC COUNSELING

Facility OP

$111.46

Service Code	EAPG 00882
Hospital Charge Code	EAPG 00882
Min. Negotiated Rate	$111.46
Max. Negotiated Rate	$111.46
Rate for Payer: Buckeye Health Medicaid OOS	$111.46
Rate for Payer: Molina Healthcare of OH Medicare	$111.46

OUTPATIENT EAPG 01001: DURABLE MEDICAL EQUIPMENT AND SUPPLIES - LEVEL 1

Facility OP

$15.94

Service Code	EAPG 01001
Hospital Charge Code	EAPG 01001
Min. Negotiated Rate	$15.94
Max. Negotiated Rate	$15.94
Rate for Payer: Buckeye Health Medicaid OOS	$15.94
Rate for Payer: Molina Healthcare of OH Medicare	$15.94

OUTPATIENT EAPG 01002: DURABLE MEDICAL EQUIPMENT AND SUPPLIES - LEVEL 2

Facility OP

$20.37

Service Code	EAPG 01002
Hospital Charge Code	EAPG 01002
Min. Negotiated Rate	$20.37
Max. Negotiated Rate	$20.37
Rate for Payer: Buckeye Health Medicaid OOS	$20.37
Rate for Payer: Molina Healthcare of OH Medicare	$20.37

OUTPATIENT EAPG 01003: DURABLE MEDICAL EQUIPMENT AND SUPPLIES - LEVEL 3

Facility OP

$29.86

Service Code	EAPG 01003
Hospital Charge Code	EAPG 01003
Min. Negotiated Rate	$29.86
Max. Negotiated Rate	$29.86
Rate for Payer: Buckeye Health Medicaid OOS	$29.86
Rate for Payer: Molina Healthcare of OH Medicare	$29.86

OUTPATIENT EAPG 01004: DURABLE MEDICAL EQUIPMENT - LEVEL 4

Facility OP

$18.70

Service Code	EAPG 01004
Hospital Charge Code	EAPG 01004
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$18.70
Rate for Payer: Buckeye Health Medicaid OOS	$18.70
Rate for Payer: Molina Healthcare of OH Medicare	$18.70

OUTPATIENT EAPG 01005: DURABLE MEDICAL EQUIPMENT - LEVEL 5

Facility OP

$54.30

Service Code	EAPG 01005
Hospital Charge Code	EAPG 01005
Min. Negotiated Rate	$54.30
Max. Negotiated Rate	$54.30
Rate for Payer: Buckeye Health Medicaid OOS	$54.30
Rate for Payer: Molina Healthcare of OH Medicare	$54.30

OUTPATIENT EAPG 01006: DURABLE MEDICAL EQUIPMENT - LEVEL 6

Facility OP

$47.94

Service Code	EAPG 01006
Hospital Charge Code	EAPG 01006
Min. Negotiated Rate	$47.94
Max. Negotiated Rate	$47.94
Rate for Payer: Buckeye Health Medicaid OOS	$47.94
Rate for Payer: Molina Healthcare of OH Medicare	$47.94

OUTPATIENT EAPG 01007: DURABLE MEDICAL EQUIPMENT - LEVEL 7

Facility OP

$80.59

Service Code	EAPG 01007
Hospital Charge Code	EAPG 01007
Min. Negotiated Rate	$80.59
Max. Negotiated Rate	$80.59
Rate for Payer: Buckeye Health Medicaid OOS	$80.59
Rate for Payer: Molina Healthcare of OH Medicare	$80.59

OUTPATIENT EAPG 01008: DURABLE MEDICAL EQUIPMENT - LEVEL 8

Facility OP

$108.71

Service Code	EAPG 01008
Hospital Charge Code	EAPG 01008
Min. Negotiated Rate	$108.71
Max. Negotiated Rate	$108.71
Rate for Payer: Buckeye Health Medicaid OOS	$108.71
Rate for Payer: Molina Healthcare of OH Medicare	$108.71

OUTPATIENT EAPG 01009: DURABLE MEDICAL EQUIPMENT - LEVEL 9

Facility OP

$202.00

Service Code	EAPG 01009
Hospital Charge Code	EAPG 01009
Min. Negotiated Rate	$202.00
Max. Negotiated Rate	$202.00
Rate for Payer: Buckeye Health Medicaid OOS	$202.00
Rate for Payer: Molina Healthcare of OH Medicare	$202.00

OUTPATIENT EAPG 01010: DURABLE MEDICAL EQUIPMENT - LEVEL 10

Facility OP

$383.09

Service Code	EAPG 01010
Hospital Charge Code	EAPG 01010
Min. Negotiated Rate	$383.09
Max. Negotiated Rate	$383.09
Rate for Payer: Buckeye Health Medicaid OOS	$383.09
Rate for Payer: Molina Healthcare of OH Medicare	$383.09

OUTPATIENT EAPG 01011: DURABLE MEDICAL EQUIPMENT - LEVEL 11

Facility OP

$543.67

Service Code	EAPG 01011
Hospital Charge Code	EAPG 01011
Min. Negotiated Rate	$543.67
Max. Negotiated Rate	$543.67
Rate for Payer: Buckeye Health Medicaid OOS	$543.67
Rate for Payer: Molina Healthcare of OH Medicare	$543.67

OUTPATIENT EAPG 01015: DURABLE MEDICAL EQUIPMENT - LEVEL 15

Facility OP

$1,461.83

Service Code	EAPG 01015
Hospital Charge Code	EAPG 01015
Min. Negotiated Rate	$1,461.83
Max. Negotiated Rate	$1,461.83
Rate for Payer: Buckeye Health Medicaid OOS	$1,461.83
Rate for Payer: Molina Healthcare of OH Medicare	$1,461.83

OXCARBAZEPINE 150 MG ORAL TAB

Facility OP

$2.00

Service Code	NDC 62756018388
Hospital Charge Code	27049
Hospital Revenue Code	637
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna Commercial	$1.68
Rate for Payer: Aetna Medicare	$0.66
Rate for Payer: Anthem Blue Cross of IN Medicare	$0.66
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange	$1.15
Rate for Payer: Anthem Blue Cross of IN Traditional	$1.25
Rate for Payer: CareSource Indiana of IN Just 4 Me	$0.76
Rate for Payer: CareSource Indiana of IN Medicare	$0.72
Rate for Payer: Cash Price	$1.24
Rate for Payer: Centivo All Commercial	$1.02
Rate for Payer: Cigna All Commercial	$1.72
Rate for Payer: CORVEL All Commercial	$1.86
Rate for Payer: Coventry All Commercial	$1.76
Rate for Payer: Encore All Commercial	$1.84
Rate for Payer: Frontpath All Commercial	$1.84
Rate for Payer: Humana ChoiceCare	$1.72
Rate for Payer: Humana Medicare	$1.02
Rate for Payer: Lucent All Commercial	$1.02
Rate for Payer: Lutheran Preferred All Commercial	$1.80
Rate for Payer: PHCS All Commercial	$1.50
Rate for Payer: PHP All Commercial	$1.51
Rate for Payer: Plain Church Group Ministry All Commercial	$0.78
Rate for Payer: Sagamore Health Network All Products	$1.54
Rate for Payer: Signature Care EPO	$1.66
Rate for Payer: Signature Care PPO	$1.76
Rate for Payer: Three Rivers Preferred All Commercial	$1.70
Rate for Payer: United Healthcare Commercial	$1.57
Rate for Payer: United Healthcare Medicare	$0.66

OXCARBAZEPINE 150 MG ORAL TAB

Facility IP

$2.00

Service Code	NDC 62756018388
Hospital Charge Code	27049
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna Commercial	$1.72
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cigna All Commercial	$1.72
Rate for Payer: CORVEL All Commercial	$1.86
Rate for Payer: Coventry All Commercial	$1.76
Rate for Payer: Encore All Commercial	$1.84
Rate for Payer: Frontpath All Commercial	$1.84
Rate for Payer: Humana ChoiceCare	$1.72
Rate for Payer: Lutheran Preferred All Commercial	$1.80
Rate for Payer: PHCS All Commercial	$1.50
Rate for Payer: PHP All Commercial	$1.51
Rate for Payer: Sagamore Health Network All Products	$1.54
Rate for Payer: Signature Care EPO	$1.66
Rate for Payer: Signature Care PPO	$1.76
Rate for Payer: United Healthcare Commercial	$1.57

OXYCODONE 10 MG ORAL TR12

Facility IP

$30.53

Service Code	NDC 59011041020
Hospital Charge Code	171241
Hospital Revenue Code	250
Min. Negotiated Rate	$22.90
Max. Negotiated Rate	$28.40
Rate for Payer: Aetna Commercial	$26.38
Rate for Payer: Cash Price	$18.93
Rate for Payer: Cigna All Commercial	$26.35
Rate for Payer: CORVEL All Commercial	$28.40
Rate for Payer: Coventry All Commercial	$26.87
Rate for Payer: Encore All Commercial	$28.11
Rate for Payer: Frontpath All Commercial	$28.09
Rate for Payer: Humana ChoiceCare	$26.37
Rate for Payer: Lutheran Preferred All Commercial	$27.48
Rate for Payer: PHCS All Commercial	$22.90
Rate for Payer: PHP All Commercial	$23.16
Rate for Payer: Sagamore Health Network All Products	$23.57
Rate for Payer: Signature Care EPO	$25.34
Rate for Payer: Signature Care PPO	$26.87
Rate for Payer: United Healthcare Commercial	$24.06

OXYCODONE 10 MG ORAL TR12

Facility OP

$30.53

Service Code	NDC 59011041020
Hospital Charge Code	171241
Hospital Revenue Code	637
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$28.40
Rate for Payer: Aetna Commercial	$25.77
Rate for Payer: Aetna Medicare	$10.08
Rate for Payer: Anthem Blue Cross of IN Medicare	$10.08
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange	$17.54
Rate for Payer: Anthem Blue Cross of IN Traditional	$19.09
Rate for Payer: CareSource Indiana of IN Just 4 Me	$11.59
Rate for Payer: CareSource Indiana of IN Medicare	$11.08
Rate for Payer: Cash Price	$18.93
Rate for Payer: Centivo All Commercial	$15.57
Rate for Payer: Cigna All Commercial	$26.35
Rate for Payer: CORVEL All Commercial	$28.40
Rate for Payer: Coventry All Commercial	$26.87
Rate for Payer: Encore All Commercial	$28.11
Rate for Payer: Frontpath All Commercial	$28.09
Rate for Payer: Humana ChoiceCare	$26.37
Rate for Payer: Humana Medicare	$15.57
Rate for Payer: Lucent All Commercial	$15.57
Rate for Payer: Lutheran Preferred All Commercial	$27.48
Rate for Payer: PHCS All Commercial	$22.90
Rate for Payer: PHP All Commercial	$23.16
Rate for Payer: Plain Church Group Ministry All Commercial	$11.91
Rate for Payer: Sagamore Health Network All Products	$23.57
Rate for Payer: Signature Care EPO	$25.34
Rate for Payer: Signature Care PPO	$26.87
Rate for Payer: Three Rivers Preferred All Commercial	$25.95
Rate for Payer: United Healthcare Commercial	$24.06
Rate for Payer: United Healthcare Medicare	$10.08

OXYCODONE 15 MG ORAL TAB

Facility OP

$5.24

Service Code	NDC 00406851562
Hospital Charge Code	28899
Hospital Revenue Code	637
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$4.88
Rate for Payer: Aetna Commercial	$4.43
Rate for Payer: Aetna Medicare	$1.73
Rate for Payer: Anthem Blue Cross of IN Medicare	$1.73
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange	$3.01
Rate for Payer: Anthem Blue Cross of IN Traditional	$3.28
Rate for Payer: CareSource Indiana of IN Just 4 Me	$1.99
Rate for Payer: CareSource Indiana of IN Medicare	$1.90
Rate for Payer: Cash Price	$3.25
Rate for Payer: Centivo All Commercial	$2.67
Rate for Payer: Cigna All Commercial	$4.52
Rate for Payer: CORVEL All Commercial	$4.88
Rate for Payer: Coventry All Commercial	$4.61
Rate for Payer: Encore All Commercial	$4.83
Rate for Payer: Frontpath All Commercial	$4.82
Rate for Payer: Humana ChoiceCare	$4.53
Rate for Payer: Humana Medicare	$2.67
Rate for Payer: Lucent All Commercial	$2.67
Rate for Payer: Lutheran Preferred All Commercial	$4.72
Rate for Payer: PHCS All Commercial	$3.93
Rate for Payer: PHP All Commercial	$3.98
Rate for Payer: Plain Church Group Ministry All Commercial	$2.04
Rate for Payer: Sagamore Health Network All Products	$4.05
Rate for Payer: Signature Care EPO	$4.35
Rate for Payer: Signature Care PPO	$4.61
Rate for Payer: Three Rivers Preferred All Commercial	$4.46
Rate for Payer: United Healthcare Commercial	$4.13
Rate for Payer: United Healthcare Medicare	$1.73

OXYCODONE 15 MG ORAL TAB

Facility IP

$5.24

Service Code	NDC 00406851562
Hospital Charge Code	28899
Hospital Revenue Code	250
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$4.88
Rate for Payer: Aetna Commercial	$4.53
Rate for Payer: Cash Price	$3.25
Rate for Payer: Cigna All Commercial	$4.52
Rate for Payer: CORVEL All Commercial	$4.88
Rate for Payer: Coventry All Commercial	$4.61
Rate for Payer: Encore All Commercial	$4.83
Rate for Payer: Frontpath All Commercial	$4.82
Rate for Payer: Humana ChoiceCare	$4.53
Rate for Payer: Lutheran Preferred All Commercial	$4.72
Rate for Payer: PHCS All Commercial	$3.93
Rate for Payer: PHP All Commercial	$3.98
Rate for Payer: Sagamore Health Network All Products	$4.05
Rate for Payer: Signature Care EPO	$4.35
Rate for Payer: Signature Care PPO	$4.61
Rate for Payer: United Healthcare Commercial	$4.13

OXYCODONE 40 MG ORAL TR12

Facility IP

$97.38

Service Code	NDC 59011044020
Hospital Charge Code	171245
Hospital Revenue Code	250
Min. Negotiated Rate	$73.04
Max. Negotiated Rate	$90.57
Rate for Payer: Aetna Commercial	$84.14
Rate for Payer: Cash Price	$60.38
Rate for Payer: Cigna All Commercial	$84.04
Rate for Payer: CORVEL All Commercial	$90.57
Rate for Payer: Coventry All Commercial	$85.70
Rate for Payer: Encore All Commercial	$89.64
Rate for Payer: Frontpath All Commercial	$89.59
Rate for Payer: Humana ChoiceCare	$84.11
Rate for Payer: Lutheran Preferred All Commercial	$87.65
Rate for Payer: PHCS All Commercial	$73.04
Rate for Payer: PHP All Commercial	$73.86
Rate for Payer: Sagamore Health Network All Products	$75.18
Rate for Payer: Signature Care EPO	$80.83
Rate for Payer: Signature Care PPO	$85.70
Rate for Payer: United Healthcare Commercial	$76.74

OXYCODONE 40 MG ORAL TR12

Facility OP

$97.38

Service Code	NDC 59011044020
Hospital Charge Code	171245
Hospital Revenue Code	637
Min. Negotiated Rate	$32.14
Max. Negotiated Rate	$90.57
Rate for Payer: Aetna Commercial	$82.19
Rate for Payer: Aetna Medicare	$32.14
Rate for Payer: Anthem Blue Cross of IN Medicare	$32.14
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange	$55.93
Rate for Payer: Anthem Blue Cross of IN Traditional	$60.87
Rate for Payer: CareSource Indiana of IN Just 4 Me	$36.96
Rate for Payer: CareSource Indiana of IN Medicare	$35.35
Rate for Payer: Cash Price	$60.38
Rate for Payer: Centivo All Commercial	$49.67
Rate for Payer: Cigna All Commercial	$84.04
Rate for Payer: CORVEL All Commercial	$90.57
Rate for Payer: Coventry All Commercial	$85.70
Rate for Payer: Encore All Commercial	$89.64
Rate for Payer: Frontpath All Commercial	$89.59
Rate for Payer: Humana ChoiceCare	$84.11
Rate for Payer: Humana Medicare	$49.67
Rate for Payer: Lucent All Commercial	$49.67
Rate for Payer: Lutheran Preferred All Commercial	$87.65
Rate for Payer: PHCS All Commercial	$73.04
Rate for Payer: PHP All Commercial	$73.86
Rate for Payer: Plain Church Group Ministry All Commercial	$37.98
Rate for Payer: Sagamore Health Network All Products	$75.18
Rate for Payer: Signature Care EPO	$80.83
Rate for Payer: Signature Care PPO	$85.70
Rate for Payer: Three Rivers Preferred All Commercial	$82.78
Rate for Payer: United Healthcare Commercial	$76.74
Rate for Payer: United Healthcare Medicare	$32.14

OXYCODONE 5 MG ORAL TAB

Facility IP

$4.00

Service Code	NDC 00904696661
Hospital Charge Code	10814
Hospital Revenue Code	250
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$3.72
Rate for Payer: Aetna Commercial	$3.46
Rate for Payer: Cash Price	$2.48
Rate for Payer: Cigna All Commercial	$3.45
Rate for Payer: CORVEL All Commercial	$3.72
Rate for Payer: Coventry All Commercial	$3.52
Rate for Payer: Encore All Commercial	$3.68
Rate for Payer: Frontpath All Commercial	$3.68
Rate for Payer: Humana ChoiceCare	$3.45
Rate for Payer: Lutheran Preferred All Commercial	$3.60
Rate for Payer: PHCS All Commercial	$3.00
Rate for Payer: PHP All Commercial	$3.03
Rate for Payer: Sagamore Health Network All Products	$3.09
Rate for Payer: Signature Care EPO	$3.32
Rate for Payer: Signature Care PPO	$3.52
Rate for Payer: United Healthcare Commercial	$3.15

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