ST. LUKE’S CHARGE 10002800 HYDROMORPHONE PCA 0.2 MG/ML SOLN (PEDIATRIC > 45 KG) (RESTRICTED) (DISCRETE FIELDS) Insurance and Self Pay Discounts 250 J1170 71286-2010-1 $164.81

Aurora ST. LUKE’S
CHARGE
10002800
HYDROMORPHONE PCA 0.2 MG/ML SOLN (PEDIATRIC > 45 KG) (RESTRICTED) (DISCRETE FIELDS)
Rev 250
CPT J1170
NDC 71286-2010-1

Fee $164.81

Self-Pay $81.24

Insurance

Minimum $82.41
Maximum $139.11
Aetna W $60.51
Aetna PPO $135.98
Anthem Blue Priority $67.81
Anthem Blue Preferred $67.81
Anthem PPO $139.11
Aurora Caregiver $71.43
Centivo $71.43
Cigna GPPO $88.76
Cigna PPO $138.56
Common Ground ETF Network $67.72
Common Ground Exchange Envision $67.72
Common Ground Group Envision $67.72
Everpointe Elite $64.46
Health EOS Plus $99.98
Health EOS PPO $130.72
HealthPartners ETF $69.05
HealthPartners Robin Focused $86.02
HealthPartners Broad $122.91
HPS $81.56
HST $82.16
Humana HPN $76.38
Humana HMO $76.38
Humana PPO $137.79
Molina Exchange $67.36
Quartz One $65.07
Quartz Group $72.82
Trilogy $85.64
UHC Individual Exchange $72.55
UHC Charter $72.55
UHC Nexus $72.55
UHC HMO $79.33
UHC PPO $138.15
WPS Aurora Featured Network $77.18
WPS Arise $81.24
WPS Statewide $81.24