Medical Procedure Costs

67110

Repair detached retina

Surgery - Eye

$698

—

67112010100

TRICARE PRENATAL TABLET

Prescription Drug - Brand

$1

—

67112040190

TRICARE PRENATAL DHA ONE SFTGL

Prescription Drug - Brand

$2

—

67113

Repair retinal detach cplx

Surgery - Eye

$1,110

—

67115

Release encircling material

Surgery - Eye

$432

—

67120

Remove eye implant material

Surgery - Eye

$476

—

67121

Remove eye implant material

Surgery - Eye

$765

—

67141

Proph rta dtchmnt crtx dthrm

Surgery - Eye

$189

—

67145

Proph rta dtchmnt pc

Surgery - Eye

$189

—

67208

Treatment of retinal lesion

Surgery - Eye

$492

—

67210

Treatment of retinal lesion

Surgery - Eye

$428

—

67218

Treatment of retinal lesion

Surgery - Eye

$1,155

—

67220

Treatment of choroid lesion

Surgery - Eye

$428

—

67221

Ocular photodynamic ther

Surgery - Eye

$168

—

67225

Eye photodynamic ther add-on

Surgery - Eye

$22

—

67227

Dstrj extensive retinopathy

Surgery - Eye

$215

—

67228

Treatment x10sv retinopathy

Surgery - Eye

$254

—

67229

Tr retinal les preterm inf

Surgery - Eye

$970

—

67250

Reinforce eye wall

Surgery - Eye

$796

—

67253018010

AMPICILLIN 250 MG CAPSULE

Prescription Drug - Generic

$0

—

67253018050

AMPICILLIN TR 250 MG CAPSULE

Prescription Drug - Generic

$0

—

67253018150

AMPICILLIN TR 500 MG CAPSULE

Prescription Drug - Generic

$0

—

67255

Reinforce/graft eye wall

Surgery - Eye

$597

—

67311

Revise eye muscle

Surgery - Eye

$391

—

67312

Revise two eye muscles

Surgery - Eye

$558

—

67314

Revise eye muscle

Surgery - Eye

$391

—

67316

Revise two eye muscles

Surgery - Eye

$596

—

67318

Revise eye muscle(s)

Surgery - Eye

$579

—

67320

Revise eye muscle(s) add-on

Surgery - Eye

$140

—

67331

Eye surgery follow-up add-on

Surgery - Eye

$101

—

67332

Rerevise eye muscles add-on

Surgery - Eye

$162

—

67334

Revise eye muscle w/suture

Surgery - Eye

$100

—

67335

Eye suture during surgery

Surgery - Eye

$150

—

67340

Revise eye muscle add-on

Surgery - Eye

$233

—

67343

Release eye tissue

Surgery - Eye

$583

—

67345

Destroy nerve of eye muscle

Surgery - Eye

$191

—

67346

Biopsy eye muscle

Surgery - Eye

$161

—

67386031321

ONFI 2.5 MG/ML SUSPENSION

Prescription Drug - Brand

$12

—

67386031401

ONFI 10 MG TABLET

Prescription Drug - Brand

$30

—

67386031501

ONFI 20 MG TABLET

Prescription Drug - Brand

$60

—

67400

Explore/biopsy eye socket

Surgery - Eye

$911

—

67405

Explore/drain eye socket

Surgery - Eye

$802

—

67412

Explore/treat eye socket

Surgery - Eye

$874

—

67413

Explore/treat eye socket

Surgery - Eye

$847

—

67414

Explr/decompress eye socket

Surgery - Eye

$1,249

—

67415

Aspiration orbital contents

Surgery - Eye

$82

—

67420

Explore/treat eye socket

Surgery - Eye

$1,504

—

67430

Explore/treat eye socket

Surgery - Eye

$1,213

—

67440

Explore/drain eye socket

Surgery - Eye

$1,176

—

67445

Explr/decompress eye socket

Surgery - Eye

$1,312

—

My Cost List