ST. LUKE’S CHARGE 10002800 LEVETIRACETAM 500 MG/5ML IV SOLN Insurance and Self Pay Discounts 250 J1953 0409-1886-02 $60.40

Aurora ST. LUKE’S
CHARGE
10002800
LEVETIRACETAM 500 MG/5ML IV SOLN
Rev 250
CPT J1953
NDC 0409-1886-02

Fee $60.40

Self-Pay $33.24

Insurance

Minimum $30.20
Maximum $51.02
Aetna W $25.49
Aetna PPO $50.07
Anthem Blue Priority $27.50
Anthem Blue Preferred $27.50
Anthem PPO $51.02
Aurora Caregiver $28.69
Centivo $28.54
Cigna GPPO $33.37
Cigna PPO $50.86
Common Ground ETF Network $29.05
Common Ground Exchange Envision $29.05
Common Ground Group Envision $29.05
Everpointe Elite $25.72
Health EOS Plus $36.70
Health EOS PPO $48.00
HealthPartners ETF $28.30
HealthPartners Robin Focused $34.12
HealthPartners Broad $45.12
HPS $33.50
HST $33.04
Humana HPN $28.92
Humana HMO $28.92
Humana PPO $50.73
Molina Exchange $26.36
Quartz One $26.01
Quartz Group $29.20
Trilogy $32.70
UHC Individual Exchange $38.14
UHC Charter $38.14
UHC Nexus $38.14
UHC HMO $40.53
UHC PPO $50.73
WPS Aurora Featured Network $31.58
WPS Arise $33.24
WPS Statewide $33.24