ST. LUKE’S CHARGE 10002791 PLT PHER L/R CMV-NEG IRR EA UN Insurance and Self Pay Discounts 390 P9053 $2,060.00

Aurora ST. LUKE’S
CHARGE
10002791
PLT PHER L/R CMV-NEG IRR EA UN
Rev 390
CPT P9053
NDC NA

Fee $2,060.00

Self-Pay $1,093.02

Insurance

Minimum $1,030.00
Maximum $1,656.68
Aetna W $968.00
Aetna PPO $1,561.46
Anthem Blue Priority $1,041.76
Anthem Blue Preferred $1,041.76
Anthem PPO $1,630.13
Aurora Caregiver $1,049.37
Centivo $1,067.55
Cigna GPPO $1,288.14
Cigna PPO $1,656.68
Common Ground ETF Network $1,114.77
Common Ground Exchange Envision $1,114.77
Common Ground Group Envision $1,114.77
Everpointe Elite $961.20
Health EOS Plus $1,201.35
Health EOS PPO $1,527.13
HealthPartners ETF $966.55
HealthPartners Robin Focused $1,164.80
HealthPartners Broad $1,475.94
HPS $1,239.93
HST $1,218.38
Humana HPN $1,045.67
Humana HMO $1,045.67
Humana PPO $1,605.13
Molina Exchange $992.20
Quartz One $990.52
Quartz Group $1,129.59
Trilogy $1,245.89
UHC Individual Exchange $1,059.91
UHC Charter $1,072.24
UHC Nexus $1,072.24
UHC HMO $1,140.86
UHC PPO $1,606.01
WPS Aurora Featured Network $1,038.37
WPS Arise $1,093.02
WPS Statewide $1,093.02