Medical Procedure Costs

49884021374

ALPRAZOLAM ODT 1 MG TAB

Prescription Drug - Generic

$2

—

49884023183

PRAZIQUANTEL 600 MG TABLET

Prescription Drug - Generic

$55

—

49884025011

OLANZAPINE-FLUOXETINE 6-25 MG

Prescription Drug - Generic

$4

—

49884025111

OLANZAPINE-FLUOXETINE 6-50 MG

Prescription Drug - Generic

$5

—

49884025211

OLANZAPINE-FLUOXETINE 12-25 MG

Prescription Drug - Generic

$7

—

49884025311

OLANZAPINE-FLUOXETINE 12-50 MG

Prescription Drug - Generic

$7

—

49884027082

NASCOBAL 500 MCG NASAL SPRAY

Prescription Drug - Brand

$172

—

49884027711

OLANZAPINE-FLUOXETINE 3-25 MG

Prescription Drug - Generic

$4

—

49884030652

CLONAZEPAM 0.125 MG DIS TAB

Prescription Drug - Generic

$1

—

49884030852

CLONAZEPAM 0.5 MG DIS TABLET

Prescription Drug - Generic

$0

—

49884030952

CLONAZEPAM 1 MG DIS TABLET

Prescription Drug - Generic

$1

—

49884034701

PIMOZIDE 1 MG TABLET

Prescription Drug - Generic

$1

—

49884034801

PIMOZIDE 2 MG TABLET

Prescription Drug - Generic

$2

—

49884046255

FENTANYL CITRATE OTFC 800 MCG

Prescription Drug - Generic

$13

—

49884083011

DILTIAZEM 24HR CD 180 MG CAP

Prescription Drug - Generic

$0

—

49884083209

DILTIAZEM 24HR CD 300 MG CAP

Prescription Drug - Generic

$1

—

49884088299

LAMOTRIGINE ODT KIT (ORANGE)

Prescription Drug - Generic

$10

—

49884089852

ZOLPIDEM TART 1.75 MG TAB SL

Prescription Drug - Generic

$5

—

49884089952

ZOLPIDEM TART 3.5 MG TABLET SL

Prescription Drug - Generic

$5

—

49884094969

MEGACE ES 625 MG/5 ML SUSP

Prescription Drug - Brand

$6

—

49900

Repair of abdominal wall

Surgery - Digestive

$800

—

49904

Omental flap extra-abdom

Surgery - Digestive

$1,288

—

49905

Omental flap intra-abdom

Surgery - Digestive

$315

—

49908015030

PRAMCORT 1% CREAM

Prescription Drug - Generic

$1

—

49908016790

FORMALDEHYDE 10% SOLUTION

Prescription Drug - Generic

$0

—

50010

Renal exploration

Surgery - Urinary

$641

—

50020

Drg perirnl/renal absc open

Surgery - Urinary

$916

—

50040

Nfros nfrot w/drg

Surgery - Urinary

$833

—

50045

Nephrotomy w/exploration

Surgery - Urinary

$839

—

50060

Nl removal calculus

Surgery - Urinary

$1,019

—

50065

Nl sec surg operj calculus

Surgery - Urinary

$1,078

—

50070

Nl comp cgen kdn abnormality

Surgery - Urinary

$1,058

—

50075

Nl rmvl lg staghorn calculus

Surgery - Urinary

$1,297

—

50080

Perq nl/pl lithotrp smpl<2cm

Surgery - Urinary

$629

—

50081

Perq nl/pl lithotrp cplx>2cm

Surgery - Urinary

$1,002

—

50100

Trnsxj/repos abrrnt rnl vsls

Surgery - Urinary

$1,025

—

50102010048

LYZA 0.35 MG TABLET

Prescription Drug - Generic

$0

—

50102011112

ECONTRA EZ 1.5 MG TABLET

Prescription Drug - Generic

$7

—

50102012048

AUBRA-28 TABLET

Prescription Drug - Generic

$0

—

50102012803

TARINA FE 1-20 TABLET

Prescription Drug - Generic

$0

—

50102013048

CHATEAL-28 TABLET

Prescription Drug - Generic

$0

—

50102015403

CYRED 28 DAY TABLET

Prescription Drug - Generic

$0

—

50102020013

TULANA 0.35 MG TABLET

Prescription Drug - Generic

$0

—

50102021116

ECONTRA ONE-STEP 1.5 MG TABLET

Prescription Drug - Generic

$6

—

50102022023

AUBRA EQ-28 TABLET

Prescription Drug - Generic

$0

—

50102022423

TARINA 24 FE 1 MG-20 MCG TAB

Prescription Drug - Generic

$0

—

50102022823

TARINA FE 1-20 EQ TABLET

Prescription Drug - Generic

$0

—

50102023023

CHATEAL EQ-28 TABLET

Prescription Drug - Generic

$0

—

50102023113

TRI-VYLIBRA LO TABLET

Prescription Drug - Generic

$0

—

50102023313

TRI-VYLIBRA 28 TABLET

Prescription Drug - Generic

$0

—

My Cost List