Medical Procedure Costs

50102023513

VYLIBRA 28 TABLET

Prescription Drug - Generic

$0

—

50102024023

JASMIEL 3 MG-0.02 MG TABLET

Prescription Drug - Generic

$0

—

50102025423

CYRED EQ 28 DAY TABLET

Prescription Drug - Generic

$0

—

50102030013

LYLEQ 0.35 MG TABLET

Prescription Drug - Generic

$0

—

50111048302

THEOPHYLLINE ER 100 MG TABLET

Prescription Drug - Generic

$0

—

50111051801

THEOPHYLLINE ER 450 MG TAB

Prescription Drug - Generic

$1

—

50120

Pyelotomy w/exploration

Surgery - Urinary

$853

—

50125

Pyelotomy w/drg pyelostomy

Surgery - Urinary

$882

—

50130

Pyelotomy w/removal calculus

Surgery - Urinary

$926

—

50200

Renal biopsy perq

Surgery - Urinary

$110

—

50205

Renal bx surg exposure kdn

Surgery - Urinary

$713

—

50220

Remove kidney open

Surgery - Urinary

$963

—

50222021130

PROTOPIC 0.1% OINTMENT

Prescription Drug - Brand

$9

—

50222022704

TACLONEX OINTMENT

Prescription Drug - Brand

$18

—

50222026012

DOVONEX 0.005% CREAM

Prescription Drug - Brand

$12

—

50222030260

ENSTILAR 0.005%-0.064% FOAM

Prescription Drug - Brand

$22

—

50222030350

FINACEA 15% FOAM

Prescription Drug - Brand

$8

—

50222050106

TACLONEX 0.005%-0.064% SUSPENSION

Prescription Drug - Brand

$21

—

50222050247

PICATO 0.015% GEL

Prescription Drug - Brand

$357

—

50222050347

PICATO 0.05% GEL

Prescription Drug - Brand

$531

—

50225

Removal kidney open complex

Surgery - Urinary

$1,059

—

50228017660

BUPROPION HCL SR 200 MG TABLET

Prescription Drug - Generic

$0

—

50228048305

DILTIAZEM 90 MG TABLET

Prescription Drug - Generic

$0

—

50230

Removal kidney open radical

Surgery - Urinary

$1,143

—

50234

Removal of kidney & ureter

Surgery - Urinary

$1,161

—

50236

Removal of kidney & ureter

Surgery - Urinary

$1,307

—

50240

Nephrectomy partial

Surgery - Urinary

$1,191

—

50242004164

CATHFLO ACTIVASE 2 MG VIAL

Prescription Drug - Brand

$186

—

50242006201

TARCEVA 25 MG TABLET

Prescription Drug - Brand

$64

—

50242006301

TARCEVA 100 MG TABLET

Prescription Drug - Brand

$177

—

50242006401

TARCEVA 150 MG TABLET

Prescription Drug - Brand

$202

—

50242010040

PULMOZYME 1 MG/ML AMPUL

Prescription Drug - Brand

$53

—

50242013801

ACTEMRA 162 MG/0.9 ML SYRINGE

Prescription Drug - Brand

$1,001

—

50242014301

ACTEMRA ACTPEN 162 MG/0.9 ML

Prescription Drug - Brand

$1,279

—

50242082802

XOFLUZA 20 MG TAB (40 MG DOSE)

Prescription Drug - Brand

$73

—

50242086001

XOFLUZA 40 MG TABLET

Prescription Drug - Brand

$162

—

50242086002

XOFLUZA 40 MG TAB (80 MG DOSE)

Prescription Drug - Brand

$74

—

50242087701

XOFLUZA 80 MG TABLET

Prescription Drug - Brand

$162

—

50250

Opn abltj 1/> rnl mas crysrg

Surgery - Urinary

$1,088

—

50268004315

ARTIFICIAL TEARS 0.1-0.2-0.3%

Prescription Drug - Generic

$0

—

50268005215

ARTHRITIS PAIN ER 650 MG TAB

Prescription Drug - Generic

$0

—

50268006815

CARBOXYMETHYLCELL 0.5% EYE DRP

Prescription Drug - Generic

$0

—

50268012615

LUBRICANT 0.4-0.3% EYE DROP

Prescription Drug - Generic

$0

—

50268019560

CAPSAICIN 0.025% CREAM

Prescription Drug - Generic

$0

—

50268019657

CAPSAICIN 0.075% CREAM

Prescription Drug - Generic

$0

—

50268026815

DOCUSATE SODIUM 250 MG SOFTGEL

Prescription Drug - Generic

$0

—

50268067815

POLYVINYL ALCOHOL 1.4% EYEDROP

Prescription Drug - Generic

$0

—

50280

Exc/unroofing cyst kidney

Surgery - Urinary

$851

—

50290

Excision perinephric cyst

Surgery - Urinary

$810

—

50320

Remove kidney living donor

Surgery - Urinary

$1,483

—

My Cost List