Medical Procedure Costs

69540

Excision aural polyp

Surgery - Auditory

$120

—

69543010750

DESLORATADINE 5 MG TABLET

Prescription Drug - Generic

$0

—

69543012011

ACARBOSE 25 MG TABLET

Prescription Drug - Generic

$0

—

69543012111

ACARBOSE 50 MG TABLET

Prescription Drug - Generic

$0

—

69543012211

ACARBOSE 100 MG TABLET

Prescription Drug - Generic

$0

—

69543025116

VIRTUSSIN AC W-ALC 10-100 MG/5

Prescription Drug - Generic

$0

—

69543025204

VIRTUSSIN AC LIQUID

Prescription Drug - Generic

$0

—

69543025216

VIRTUSSIN AC 10-100 MG/5 ML LQ

Prescription Drug - Generic

$0

—

69543025316

VIRTUSSIN DAC LIQUID

Prescription Drug - Generic

$0

—

69543025850

PREPLUS CA-FE 27 MG-FA 1 MG TB

Prescription Drug - Generic

$0

—

69543026010

VIRT-CAPS SOFTGEL

Prescription Drug - Generic

$0

—

69543026790

PNV 29-1 TABLET

Prescription Drug - Generic

$0

—

69543026810

VIRT-PHOS 250 NEUTRAL TABLET

Prescription Drug - Generic

$0

—

69543034030

VIRT-PN DHA SOFTGEL

Prescription Drug - Generic

$1

—

69543035610

VP-VITE RX TABLET

Prescription Drug - Generic

$0

—

69543037030

VIRT-NATE DHA SOFTGEL

Prescription Drug - Generic

$2

—

69543041011

PHENDIMETRAZINE 35 MG TABLET

Prescription Drug - Generic

$0

—

69543045714

CIPROFLOXACIN 0.2% OTIC SOLN

Prescription Drug - Generic

$7

—

69547062702

NARCAN 4 MG NASAL SPRAY

Prescription Drug - Brand

$18

—

69550

Exc aurl glomus tum trnscanl

Surgery - Auditory

$979

—

69552

Exc aurl glomus tum trnsmstd

Surgery - Auditory

$1,429

—

69554

Exc aurl glomus tum extended

Surgery - Auditory

$2,235

—

69557011130

ZTLIDO 1.8% TOPICAL SYSTEM

Prescription Drug - Brand

$12

—

69557033301

ELYXYB 120 MG/4.8 ML SOLUTION

Prescription Drug - Brand

$31

—

69584011190

CARISOPRODOL 350 MG TABLET

Prescription Drug - Generic

$0

—

69584018110

DIPYRIDAMOLE 25 MG TABLET

Prescription Drug - Generic

$0

—

69584018210

DIPYRIDAMOLE 50 MG TABLET

Prescription Drug - Generic

$0

—

69584018310

DIPYRIDAMOLE 75 MG TABLET

Prescription Drug - Generic

$0

—

69584036195

HYDROCHLOROTHIAZIDE 25 MG TAB

Prescription Drug - Generic

$0

—

69584036290

HYDROCHLOROTHIAZIDE 50 MG TAB

Prescription Drug - Generic

$0

—

69584042590

IMIPRAMINE HCL 10 MG TABLET

Prescription Drug - Generic

$0

—

69584042690

IMIPRAMINE HCL 25 MG TABLET

Prescription Drug - Generic

$0

—

69584042790

IMIPRAMINE HCL 50 MG TABLET

Prescription Drug - Generic

$0

—

69584067190

PAROXETINE HCL 10 MG TABLET

Prescription Drug - Generic

$0

—

69584067290

PAROXETINE HCL 20 MG TABLET

Prescription Drug - Generic

$0

—

69584067390

PAROXETINE HCL 30 MG TABLET

Prescription Drug - Generic

$0

—

69584067490

PAROXETINE HCL 40 MG TABLET

Prescription Drug - Generic

$0

—

69584084410

SOTALOL 240 MG TABLET

Prescription Drug - Generic

$0

—

69601

Revj mstdc rsltg compl mstdc

Surgery - Auditory

$905

—

69602

Rev mstdc rslt mod rad mstdc

Surgery - Auditory

$966

—

69603

Revj mstdc rsltg rad mstdc

Surgery - Auditory

$1,175

—

69604

Revj mstdc rsltg tympanplsty

Surgery - Auditory

$986

—

69610

Tympanic membrane repair

Surgery - Auditory

$250

—

69616027230

FYCOMPA 2 MG TABLET

Prescription Drug - Brand

$20

—

69616027430

FYCOMPA 4 MG TABLET

Prescription Drug - Brand

$39

—

69616027630

FYCOMPA 6 MG TABLET

Prescription Drug - Brand

$39

—

69616027830

FYCOMPA 8 MG TABLET

Prescription Drug - Brand

$39

—

69616028030

FYCOMPA 10 MG TABLET

Prescription Drug - Brand

$39

—

69616028230

FYCOMPA 12 MG TABLET

Prescription Drug - Brand

$39

—

69616029038

FYCOMPA 0.5 MG/ML ORAL SUSP

Prescription Drug - Brand

$4

—

My Cost List