Medical Procedure Costs

66685101102

AMOX TR-K CLV 200-28.5/5 SUSP

Prescription Drug - Generic

$0

—

66685101202

AMOX TR-K CLV 400-57/5 SUSP

Prescription Drug - Generic

$0

—

66689071116

METHADONE 5 MG/5 ML SOLUTION

Prescription Drug - Generic

$0

—

66700

Destruction ciliary body

Surgery - Eye

$335

—

66710

Ciliary transsleral therapy

Surgery - Eye

$335

—

66711

Ecp ciliary body destruction

Surgery - Eye

$446

—

66720

Destruction ciliary body

Surgery - Eye

$362

—

66740

Destruction ciliary body

Surgery - Eye

$335

—

66758007138

CILOXAN 0.3% OINTMENT

Prescription Drug - Brand

$74

—

66758008585

AZOPT 1% EYE DROPS

Prescription Drug - Brand

$35

—

66758008675

DUREZOL 0.05% EYE DROPS

Prescription Drug - Brand

$42

—

66758008770

CIPRO HC OTIC SUSPENSION

Prescription Drug - Brand

$35

—

66758009575

TRAVATAN Z 0.004% EYE DROP

Prescription Drug - Brand

$94

—

66758014583

VIVELLE-DOT 0.025 MG PATCH

Prescription Drug - Brand

$18

—

66758014683

VIVELLE-DOT 0.0375 MG PATCH

Prescription Drug - Brand

$18

—

66758014783

VIVELLE-DOT 0.05 MG PATCH

Prescription Drug - Brand

$18

—

66758014883

VIVELLE-DOT 0.075 MG PATCH

Prescription Drug - Brand

$18

—

66758014983

VIVELLE-DOT 0.1 MG PATCH

Prescription Drug - Brand

$18

—

66758020201

KLOR-CON SPRINKLE ER 8 MEQ CAP

Prescription Drug - Brand

$0

—

66758020505

KLOR-CON SPRINKLE ER 10 MEQ CP

Prescription Drug - Brand

$0

—

66758021131

LESCOL XL 80 MG TABLET

Prescription Drug - Brand

$13

—

66758023531

FOCALIN XR 5 MG CAPSULE

Prescription Drug - Brand

$5

—

66758023601

FOCALIN XR 10 MG CAPSULE

Prescription Drug - Brand

$5

—

66758023701

FOCALIN XR 15 MG CAPSULE

Prescription Drug - Brand

$5

—

66758023801

FOCALIN XR 20 MG CAPSULE

Prescription Drug - Brand

$5

—

66758023901

FOCALIN XR 25 MG CAPSULE

Prescription Drug - Brand

$5

—

66758024201

FOCALIN XR 40 MG CAPSULE

Prescription Drug - Brand

$5

—

66758025001

FOCALIN 2.5 MG TABLET

Prescription Drug - Brand

$1

—

66758025101

FOCALIN 5 MG TABLET

Prescription Drug - Brand

$1

—

66758025201

FOCALIN 10 MG TABLET

Prescription Drug - Brand

$1

—

66758027301

RITALIN 5 MG TABLET

Prescription Drug - Brand

$1

—

66758027401

RITALIN 10 MG TABLET

Prescription Drug - Brand

$1

—

66758027501

RITALIN 20 MG TABLET

Prescription Drug - Brand

$2

—

66758095985

PROVENTIL HFA 90 MCG INHALER

Prescription Drug - Brand

$11

—

66761

Revision of iris

Surgery - Eye

$202

—

66762

Revision of iris

Surgery - Eye

$367

—

66770

Removal of inner eye lesion

Surgery - Eye

$416

—

66820

Incision secondary cataract

Surgery - Eye

$421

—

66821

After cataract laser surgery

Surgery - Eye

$275

—

66825

Reposition intraocular lens

Surgery - Eye

$730

—

66830

Removal of lens lesion

Surgery - Eye

$603

—

66840

Removal of lens material

Surgery - Eye

$591

—

66850

Removal of lens material

Surgery - Eye

$670

—

66852

Removal of lens material

Surgery - Eye

$710

—

66869010490

LIVALO 1 MG TABLET

Prescription Drug - Brand

$10

—

66869013730

LIPOFEN 50 MG CAPSULE

Prescription Drug - Brand

$3

—

66869014730

LIPOFEN 150 MG CAPSULE

Prescription Drug - Brand

$7

—

66869020490

LIVALO 2 MG TABLET

Prescription Drug - Brand

$10

—

66869040490

LIVALO 4 MG TABLET

Prescription Drug - Brand

$10

—

66869056490

SEGLENTIS 56 MG-44 MG TABLET

Prescription Drug - Brand

$4

—

My Cost List