ST. LUKE’S CHARGE 10002800 BEVACIZUMAB(COMPOUNDED) 25 MG/ML OPHTH SYRINGE (NEONATAL/ADULT) Insurance and Self Pay Discounts 250 C9257 71449-091-44 $86.85

Aurora ST. LUKE’S
CHARGE
10002800
BEVACIZUMAB(COMPOUNDED) 25 MG/ML OPHTH SYRINGE (NEONATAL/ADULT)
Rev 250
CPT C9257
NDC 71449-091-44

Fee $86.85

Self-Pay $34.47

Insurance

Minimum $43.43
Maximum $73.83
Aetna W $34.39
Aetna PPO $72.44
Anthem Blue Priority $26.90
Anthem Blue Preferred $26.90
Anthem PPO $73.83
Aurora Caregiver $27.74
Centivo $31.71
Cigna GPPO $58.30
Cigna PPO $73.47
Common Ground ETF Network $25.11
Common Ground Exchange Envision $25.11
Common Ground Group Envision $25.11
Everpointe Elite $27.80
Health EOS Plus $52.98
Health EOS PPO $69.48
HealthPartners ETF $31.96
HealthPartners Robin Focused $42.67
HealthPartners Broad $65.14
HPS $33.31
HST $32.31
Humana HPN $38.82
Humana HMO $38.82
Humana PPO $73.47
Molina Exchange $30.37
Quartz One $26.13
Quartz Group $29.03
Trilogy $42.27
UHC Individual Exchange $35.35
UHC Charter $35.35
UHC Nexus $35.35
UHC HMO $38.51
UHC PPO $73.48
WPS Aurora Featured Network $32.75
WPS Arise $34.47
WPS Statewide $34.47