ST. LUKE’S CHARGE 10002114 COMPUTER ASSIST CT/MRI IMAGE Insurance and Self Pay Discounts 360 0055T $1,730.00

Aurora ST. LUKE’S
CHARGE
10002114
COMPUTER ASSIST CT/MRI IMAGE
Rev 360
CPT 0055T
NDC NA

Fee $1,730.00

Self-Pay $782.90

Insurance

Minimum $865.00
Maximum $1,459.78
Aetna W $612.61
Aetna PPO $1,430.47
Anthem Blue Priority $632.82
Anthem Blue Preferred $632.82
Anthem PPO $1,459.78
Aurora Caregiver $696.43
Centivo $693.54
Cigna GPPO $881.32
Cigna PPO $1,455.82
Common Ground ETF Network $632.64
Common Ground Exchange Envision $632.64
Common Ground Group Envision $632.64
Everpointe Elite $633.07
Health EOS Plus $1,050.40
Health EOS PPO $1,373.28
HealthPartners ETF $707.75
HealthPartners Robin Focused $903.82
HealthPartners Broad $1,291.38
HPS $804.98
HST $789.07
Humana HPN $767.41
Humana HMO $767.41
Humana PPO $1,451.25
Molina Exchange $679.34
Quartz One $621.23
Quartz Group $690.13
Trilogy $869.85
UHC Individual Exchange $691.92
UHC Charter $699.97
UHC Nexus $699.97
UHC HMO $763.75
UHC PPO $1,451.46
WPS Aurora Featured Network $743.76
WPS Arise $782.90
WPS Statewide $782.90