ST. LUKE’S CHARGE 10002647 RRX 99M TETROFOSMIN Insurance and Self Pay Discounts 343 A9502 $685.00

Aurora ST. LUKE’S
CHARGE
10002647
RRX 99M TETROFOSMIN
Rev 343
CPT A9502
NDC NA

Fee $685.00

Self-Pay $404.79

Insurance

Minimum $342.50
Maximum $581.39
Aetna W $318.42
Aetna PPO $570.07
Anthem Blue Priority $353.13
Anthem Blue Preferred $353.13
Anthem PPO $581.39
Aurora Caregiver $354.55
Centivo $424.64
Cigna GPPO $399.29
Cigna PPO $578.84
Common Ground ETF Network $344.20
Common Ground Exchange Envision $344.20
Common Ground Group Envision $344.20
Everpointe Elite $299.42
Health EOS Plus $417.45
Health EOS PPO $547.14
HealthPartners ETF $353.65
HealthPartners Robin Focused $420.53
HealthPartners Broad $513.25
HPS $387.12
HST $324.50
Humana HPN $341.14
Humana HMO $341.14
Humana PPO $578.47
Molina Exchange $239.66
Quartz One $312.42
Quartz Group $370.12
Trilogy $426.89
UHC Individual Exchange $173.57
UHC Charter $175.59
UHC Nexus $175.59
UHC HMO $198.32
UHC PPO $578.53
WPS Aurora Featured Network $384.55
WPS Arise $404.79
WPS Statewide $404.79