Medical Procedure Costs

65649000330

TRULANCE 3 MG TABLET

Prescription Drug - Brand

$19

—

65649010302

APRISO ER 0.375 GRAM CAPSULE

Prescription Drug - Brand

$4

—

65649015090

RELISTOR 150 MG TABLET

Prescription Drug - Brand

$27

—

65649020175

MOVIPREP POWDER PACKET

Prescription Drug - Brand

$120

—

65649030103

XIFAXAN 200 MG TABLET

Prescription Drug - Brand

$11

—

65649030303

XIFAXAN 550 MG TABLET

Prescription Drug - Brand

$55

—

65649031112

DIURIL 250 MG/5 ML ORAL SUSP

Prescription Drug - Brand

$0

—

65649040001

PLENVU POWDER PACKETS

Prescription Drug - Brand

$48

—

65649055102

RELISTOR 12 MG/0.6 ML VIAL

Prescription Drug - Brand

$272

—

65649055103

RELISTOR 12 MG/0.6 ML SYRINGE

Prescription Drug - Brand

$273

—

65649055204

RELISTOR 8 MG/0.4 ML SYRINGE

Prescription Drug - Brand

$410

—

65649065103

UCERIS 2 MG RECTAL FOAM

Prescription Drug - Brand

$12

—

65649070141

OSMOPREP TABLET

Prescription Drug - Brand

$8

—

65710

Corneal transplant

Surgery - Eye

$983

—

65730

Corneal transplant

Surgery - Eye

$1,068

—

65750

Corneal transplant

Surgery - Eye

$1,070

—

65755

Corneal transplant

Surgery - Eye

$1,065

—

65756

Corneal trnspl endothelial

Surgery - Eye

$992

—

65757030001

VIVITROL 380 MG VIAL-DILUENT

Prescription Drug - Brand

$1,719

—

65757030202

VIVITROL 380 MG VIAL

Prescription Drug - Brand

$1,626

—

65757040103

ARISTADA ER 441 MG/1.6 ML SYRN

Prescription Drug - Brand

$1,000

—

65757040203

ARISTADA ER 662 MG/2.4 ML SYRN

Prescription Drug - Brand

$1,001

—

65757040303

ARISTADA ER 882 MG/3.2 ML SYRN

Prescription Drug - Brand

$1,000

—

65757040403

ARISTADA ER 1,064 MG/3.9 ML SYR

Prescription Drug - Brand

$988

—

65757050003

ARISTADA INITIO ER 675 MG/2.4

Prescription Drug - Brand

$1,027

—

65757065142

LYBALVI 5-10 MG TABLET

Prescription Drug - Brand

$55

—

65757065242

LYBALVI 10-10 MG TABLET

Prescription Drug - Brand

$55

—

65757065342

LYBALVI 15-10 MG TABLET

Prescription Drug - Brand

$55

—

65757065442

LYBALVI 20-10 MG TABLET

Prescription Drug - Brand

$55

—

65770

Keratoprosthesis

Surgery - Eye

$1,182

—

65772

Correction of astigmatism

Surgery - Eye

$351

—

65775

Correction of astigmatism

Surgery - Eye

$499

—

65778

Cover eye w/membrane

Surgery - Eye

$36

—

65779

Cover eye w/membrane suture

Surgery - Eye

$85

—

65780

Ocular reconst transplant

Surgery - Eye

$516

—

65781

Ocular reconst transplant

Surgery - Eye

$1,123

—

65782

Ocular reconst transplant

Surgery - Eye

$974

—

65785

Impltj ntrstrml crnl rng seg

Surgery - Eye

$386

—

65800

Drainage of eye

Surgery - Eye

$71

—

65810

Drainage of eye

Surgery - Eye

$401

—

65815

Drainage of eye

Surgery - Eye

$412

—

65820

Goniotomy

Surgery - Eye

$723

—

65850

Trabeculotomy ab externo

Surgery - Eye

$714

—

65855

Trabeculoplasty laser surg

Surgery - Eye

$171

—

65860

Severing ads ant sgm laser

Surgery - Eye

$209

—

65862001401

AMOXICILLIN 500 MG TABLET

Prescription Drug - Generic

$0

—

65862001501

AMOXICILLIN 875 MG TABLET

Prescription Drug - Generic

$0

—

65862001605

AMOXICILLIN 250 MG CAPSULE

Prescription Drug - Generic

$0

—

65862003660

LAMIVUDINE-ZIDOVUDINE TABLET

Prescription Drug - Generic

$1

—

65862004660

STAVUDINE 30 MG CAPSULE

Prescription Drug - Generic

$1

—

My Cost List