Medical Procedure Costs

66870022016

12.5CPD-1DCPM-30PSE LIQUID

Prescription Drug - Generic

$0

—

66870040601

AMBI 60PSE-400GFN TABLET

Prescription Drug - Generic

$0

—

66870044201

AMBI 60PSE-4CPM TABLET

Prescription Drug - Generic

$0

—

66870044401

AMBI 10PEH-4CPM TABLET

Prescription Drug - Generic

$0

—

66887000105

TESTIM 1% (50 MG) GEL

Prescription Drug - Brand

$4

—

66920

Extraction of lens

Surgery - Eye

$635

—

66930

Extraction of lens

Surgery - Eye

$726

—

66940

Extraction of lens

Surgery - Eye

$668

—

66982

Xcapsl ctrc rmvl cplx wo ecp

Surgery - Eye

$631

—

66984

Xcapsl ctrc rmvl w/o ecp

Surgery - Eye

$463

—

66985

Insert lens prosthesis

Surgery - Eye

$659

—

66986

Exchange lens prosthesis

Surgery - Eye

$764

—

66989

Xcpsl ctrc rmvl cplx insj 1+

Surgery - Eye

$719

—

66990

Ophthalmic endoscope add-on

Surgery - Eye

$70

—

66991

Xcapsl ctrc rmvl insj 1+

Surgery - Eye

$582

—

66993000210

ESTRADIOL 0.01% CREAM

Prescription Drug - Generic

$0

—

66993007896

FLUTICASONE PROPIONATE HFA 44 MCG INHALER

Prescription Drug - Generic

$12

—

66993007996

FLUTICASONE PROPIONATE HFA 110 MCG INHALER

Prescription Drug - Generic

$14

—

66993008096

FLUTICASONE PROPIONATE HFA 220 MCG INHALER

Prescription Drug - Generic

$22

—

66993008169

SUMATRIPTAN 5 MG NASAL SPRAY

Prescription Drug - Generic

$20

—

66993008398

SUMATRIPTAN 4 MG/0.5 ML INJECT

Prescription Drug - Generic

$133

—

66993008479

SUMATRIPTAN 6 MG/0.5 ML CART

Prescription Drug - Generic

$124

—

66993008498

SUMATRIPTAN 6 MG/0.5 ML INJECT

Prescription Drug - Generic

$66

—

66993008696

FLUTICASONE-SALMETEROL 45-21

Prescription Drug - Generic

$17

—

66993008796

FLUTICASONE-SALMETEROL 115-21

Prescription Drug - Generic

$21

—

66993008896

FLUTICASONE-SALMETEROL 230-21

Prescription Drug - Generic

$27

—

66993013497

UMECLIDINIUM-VILANTEROL ELLIPTA 62.5-25 MCG INH

Prescription Drug - Generic

$5

—

66993013597

FLUTICASONE-VILANTEROL 100-25

Prescription Drug - Generic

$4

—

66993013697

FLUTICASONE-VILANTEROL 200-25

Prescription Drug - Generic

$4

—

66993014130

ALISKIREN 150 MG TABLET

Prescription Drug - Generic

$4

—

66993014230

ALISKIREN 300 MG TABLET

Prescription Drug - Generic

$5

—

66993016697

FLUTICASONE ELLIPTA 50 MCG INH

Prescription Drug - Generic

$4

—

66993016797

FLUTICASONE ELLIPTA 100 MCG INH

Prescription Drug - Generic

$4

—

66993016897

FLUTICASONE ELLIPTA 200 MCG INH

Prescription Drug - Generic

$6

—

66993018550

DOXERCALCIFEROL 0.5 MCG CAP

Prescription Drug - Generic

$10

—

66993018650

DOXERCALCIFEROL 1 MCG CAPSULE

Prescription Drug - Generic

$18

—

66993018802

SPIRONOLACTONE-HYDROCHLOROTHIAZIDE 25-25 TAB

Prescription Drug - Generic

$1

—

66993024150

NITROGLYCERIN 400 MCG SPRAY

Prescription Drug - Generic

$24

—

66993026330

AMLODIPINE-ATORVAST 2.5-10 MG

Prescription Drug - Generic

$4

—

66993026530

AMLODIPINE-ATORVAST 2.5-40 MG

Prescription Drug - Generic

$4

—

66993026630

AMLODIPINE-ATORVAST 5-10 MG

Prescription Drug - Generic

$1

—

66993026730

AMLODIPINE-ATORVAST 5-20 MG

Prescription Drug - Generic

$1

—

66993026830

AMLODIPINE-ATORVAST 5-40 MG

Prescription Drug - Generic

$2

—

66993026930

AMLODIPINE-ATORVAST 5-80 MG

Prescription Drug - Generic

$2

—

66993027030

AMLODIPINE-ATORVAST 10-10 MG

Prescription Drug - Generic

$1

—

66993027130

AMLODIPINE-ATORVAST 10-20 MG

Prescription Drug - Generic

$1

—

66993027230

AMLODIPINE-ATORVAST 10-40 MG

Prescription Drug - Generic

$2

—

66993027330

AMLODIPINE-ATORVAST 10-80 MG

Prescription Drug - Generic

$2

—

66993035957

DEXTROAMPHETAMINE 5 MG/5 ML

Prescription Drug - Generic

$1

—

66993036160

DAPAGLIFLOZIN-METFORMIN ER 5-1,000 MG TABLET

Prescription Drug - Generic

$6

—

My Cost List