Medical Procedure Costs

58468013102

RENVELA 2.4 GM POWDER PACKET

Prescription Drug - Brand

$17

—

58468013202

RENVELA 0.8 GM POWDER PACKET

Prescription Drug - Brand

$17

—

58468013301

RENVELA 800 MG TABLET

Prescription Drug - Brand

$6

—

58520

Repair of ruptured uterus

Surgery - Female Genital

$706

—

58540

Revision of uterus

Surgery - Female Genital

$809

—

58541

Lsh uterus 250 g or less

Surgery - Female Genital

$649

—

58542

Lsh w/t/o ut 250 g or less

Surgery - Female Genital

$733

—

58543

Lsh uterus above 250 g

Surgery - Female Genital

$743

—

58544

Lsh w/t/o uterus above 250 g

Surgery - Female Genital

$802

—

58545

Laparoscopic myomectomy

Surgery - Female Genital

$808

—

58546

Laparo-myomectomy complex

Surgery - Female Genital

$980

—

58548

Lap radical hyst

Surgery - Female Genital

$1,728

—

58550

Laparo-asst vag hysterectomy

Surgery - Female Genital

$787

—

58552

Laparo-vag hyst incl t/o

Surgery - Female Genital

$877

—

58553

Laparo-vag hyst complex

Surgery - Female Genital

$986

—

58554

Laparo-vag hyst w/t/o compl

Surgery - Female Genital

$1,162

—

58555

Hysteroscopy dx sep proc

Surgery - Female Genital

$135

—

58558

Hysteroscopy biopsy

Surgery - Female Genital

$204

—

58559

Hysteroscopy lysis

Surgery - Female Genital

$249

—

58560

Hysteroscopy resect septum

Surgery - Female Genital

$275

—

58561

Hysteroscopy remove myoma

Surgery - Female Genital

$314

—

58562

Hysteroscopy remove fb

Surgery - Female Genital

$195

—

58563

Hysteroscopy ablation

Surgery - Female Genital

$217

—

58565

Hysteroscopy sterilization

Surgery - Female Genital

$404

—

58570

Tlh uterus 250 g or less

Surgery - Female Genital

$727

—

58571

Tlh w/t/o 250 g or less

Surgery - Female Genital

$829

—

58572

Tlh uterus over 250 g

Surgery - Female Genital

$946

—

58573

Tlh w/t/o uterus over 250 g

Surgery - Female Genital

$1,106

—

58575

Laps tot hyst resj mal

Surgery - Female Genital

$1,776

—

58580

Transcrv abltj utrn fibrd rf

Surgery - Female Genital

$361

—

58600

Division of fallopian tube

Surgery - Female Genital

$332

—

58605

Division of fallopian tube

Surgery - Female Genital

$302

—

58605031316

MAXI-TUSS AC LIQUID

Prescription Drug - Generic

$0

—

58605040001

ALLFEN 400 MG TABLET

Prescription Drug - Generic

$0

—

58605040101

ALLFEN DM TABLET

Prescription Drug - Generic

$0

—

58605042201

MAXIPHEN TABLET

Prescription Drug - Generic

$0

—

58611

Ligate oviduct(s) add-on

Surgery - Female Genital

$65

—

58615

Occlude fallopian tube(s)

Surgery - Female Genital

$226

—

58657011060

FOCALGIN 90 DHA COMBO PACK

Prescription Drug - Brand

$2

—

58657011160

FOCALGIN CA COMBO PACK

Prescription Drug - Brand

$2

—

58657011290

FOCALGIN DSS TABLET

Prescription Drug - Generic

$2

—

58657011801

SODIUM CHLORIDE 1 GM TABLET

Prescription Drug - Generic

$0

—

58657012130

DOTHELLE DHA SOFTGEL

Prescription Drug - Generic

$1

—

58657012230

RULAVITE DHA SOFTGEL

Prescription Drug - Generic

$1

—

58657013390

THRIVITE RX TABLET

Prescription Drug - Generic

$0

—

58657016012

SODIUM FLUORIDE 0.25 (0.55) MG

Prescription Drug - Generic

$0

—

58657016112

SODIUM FLUORIDE 0.5 MG(1.1 MG)

Prescription Drug - Generic

$0

—

58657016212

SODIUM FLUORIDE 1 MG (2.2 MG)

Prescription Drug - Generic

$0

—

58657017001

M-NATAL PLUS TABLET

Prescription Drug - Generic

$0

—

58657031116

POTASS CIT-SOD CIT-CITRIC SOLN

Prescription Drug - Generic

$0

—

My Cost List