ST. LUKE’S CHARGE 10002800 MICAFUNGIN 1.5 MG/ML IV SYRINGE (< 30 KG) Insurance and Self Pay Discounts 250 J2248 99999-715-99 $131.83

Aurora ST. LUKE’S
CHARGE
10002800
MICAFUNGIN 1.5 MG/ML IV SYRINGE (< 30 KG) Rev 250 CPT J2248 NDC 99999-715-99 Fee $131.83 Self-Pay $69.36 Insurance Minimum $65.92 Maximum $104.86 Aetna W $61.79 Aetna PPO $99.05 Anthem Blue Priority $68.11 Anthem Blue Preferred $68.11 Anthem PPO $102.68 Aurora Caregiver $65.64 Centivo $66.21 Cigna GPPO $80.19 Cigna PPO $104.86 Common Ground ETF Network $72.02 Common Ground Exchange Envision $72.02 Common Ground Group Envision $72.02 Everpointe Elite $59.36 Health EOS Plus $76.13 Health EOS PPO $96.09 HealthPartners ETF $62.68 HealthPartners Robin Focused $75.76 HealthPartners Broad $93.51 HPS $78.22 HST $74.38 Humana HPN $64.71 Humana HMO $64.71 Humana PPO $100.86 Molina Exchange $59.39 Quartz One $62.05 Quartz Group $71.60 Trilogy $76.79 UHC Individual Exchange $75.88 UHC Charter $75.88 UHC Nexus $75.88 UHC HMO $80.32 UHC PPO $100.92 WPS Aurora Featured Network $65.89 WPS Arise $69.36 WPS Statewide $69.36