ST. LUKE’S CHARGE 10006791 PHOSPHOLIP A2 RECEPT AB Insurance and Self Pay Discounts 302 86255 $480.00

Aurora ST. LUKE’S
CHARGE
10006791
PHOSPHOLIP A2 RECEPT AB
Rev 302
CPT 86255
NDC NA

Fee $480.00

Self-Pay $235.91

Insurance

Minimum $240.00
Maximum $402.00
Aetna W $185.53
Aetna PPO $392.82
Anthem Blue Priority $181.35
Anthem Blue Preferred $181.35
Anthem PPO $402.00
Aurora Caregiver $186.04
Centivo $199.27
Cigna GPPO $297.52
Cigna PPO $401.63
Common Ground ETF Network $195.06
Common Ground Exchange Envision $195.06
Common Ground Group Envision $195.06
Everpointe Elite $180.07
Health EOS Plus $289.96
Health EOS PPO $377.86
HealthPartners ETF $191.50
HealthPartners Robin Focused $234.36
HealthPartners Broad $356.45
HPS $229.26
HST $237.36
Humana HPN $201.16
Humana HMO $201.16
Humana PPO $398.65
Molina Exchange $201.47
Quartz One $198.47
Quartz Group $223.20
Trilogy $251.65
UHC Individual Exchange $188.35
UHC Charter $188.35
UHC Nexus $188.35
UHC HMO $202.50
UHC PPO $399.14
WPS Aurora Featured Network $224.11
WPS Arise $235.91
WPS Statewide $235.91