ST. LUKE’S CHARGE 10002666 RRX IN111 DTPA (PER 500 UCI) Insurance and Self Pay Discounts 343 A9548 $6,030.00

Aurora ST. LUKE’S
CHARGE
10002666
RRX IN111 DTPA (PER 500 UCI)
Rev 343
CPT A9548
NDC NA

Fee $6,030.00

Self-Pay $3,890.83

Insurance

Minimum $3,015.00
Maximum $5,825.05
Aetna W $3,124.10
Aetna PPO $5,028.88
Anthem Blue Priority $3,535.40
Anthem Blue Preferred $3,535.40
Anthem PPO $5,125.50
Aurora Caregiver $3,520.43
Centivo $4,406.16
Cigna GPPO $3,615.86
Cigna PPO $5,100.90
Common Ground ETF Network $3,493.39
Common Ground Exchange Envision $3,493.39
Common Ground Group Envision $3,493.39
Everpointe Elite $2,943.40
Health EOS Plus $3,678.30
Health EOS PPO $4,824.00
HealthPartners ETF $3,532.77
HealthPartners Robin Focused $4,129.42
HealthPartners Broad $4,522.50
HPS $3,863.55
HST $2,942.06
Humana HPN $5,825.05
Humana HMO $5,825.05
Humana PPO $5,100.90
Molina Exchange $4,096.42
Quartz One $2,939.09
Quartz Group $3,525.69
Trilogy $4,159.05
UHC Individual Exchange $1,380.90
UHC Charter $1,396.97
UHC Nexus $1,396.97
UHC HMO $1,637.55
UHC PPO $5,101.38
WPS Aurora Featured Network $3,696.29
WPS Arise $3,890.83
WPS Statewide $3,890.83