ST. LUKE’S CHARGE 10002800 AMIKACIN SULFATE 1 GM/4ML IJ SOLN Insurance and Self Pay Discounts 250 J0278 23155-290-42 $65.59

Aurora ST. LUKE’S
CHARGE
10002800
AMIKACIN SULFATE 1 GM/4ML IJ SOLN
Rev 250
CPT J0278
NDC 23155-290-42

Fee $65.59

Self-Pay $34.19

Insurance

Minimum $32.80
Maximum $55.30
Aetna W $26.19
Aetna PPO $53.54
Anthem Blue Priority $19.99
Anthem Blue Preferred $19.99
Anthem PPO $55.30
Aurora Caregiver $17.28
Centivo $19.69
Cigna GPPO $38.69
Cigna PPO $54.52
Common Ground ETF Network $20.03
Common Ground Exchange Envision $20.03
Common Ground Group Envision $20.03
Everpointe Elite $18.89
Health EOS Plus $39.39
Health EOS PPO $51.43
HealthPartners ETF $18.79
HealthPartners Robin Focused $23.17
HealthPartners Broad $48.39
HPS $21.73
HST $31.98
Humana HPN $17.82
Humana HMO $17.82
Humana PPO $54.31
Molina Exchange $28.00
Quartz One $30.33
Quartz Group $35.85
Trilogy $35.18
UHC Individual Exchange $17.86
UHC Charter $17.86
UHC Nexus $17.86
UHC HMO $18.65
UHC PPO $54.30
WPS Aurora Featured Network $32.48
WPS Arise $34.19
WPS Statewide $34.19