Medical Procedure Costs

70010020701

LISDEXAMFETAMINE 20 MG CAPSULE

Prescription Drug - Generic

$3

—

70010020801

LISDEXAMFETAMINE 30 MG CAPSULE

Prescription Drug - Generic

$3

—

70010020901

LISDEXAMFETAMINE 40 MG CAPSULE

Prescription Drug - Generic

$3

—

70010021001

LISDEXAMFETAMINE 50 MG CAPSULE

Prescription Drug - Generic

$3

—

70010021101

LISDEXAMFETAMINE 60 MG CAPSULE

Prescription Drug - Generic

$3

—

70010021201

LISDEXAMFETAMINE 70 MG CAPSULE

Prescription Drug - Generic

$3

—

70010023110

TRAZODONE 50 MG TABLET

Prescription Drug - Generic

$0

—

70010023210

TRAZODONE 100 MG TABLET

Prescription Drug - Generic

$0

—

70010023305

TRAZODONE 150 MG TABLET

Prescription Drug - Generic

$0

—

70010023401

TRAZODONE 300 MG TABLET

Prescription Drug - Generic

$1

—

70010049601

METFORMIN ER 500 MG GASTRC-TB

Prescription Drug - Generic

$0

—

70010049709

METFORMIN ER 1,000 MG GASTR-TB

Prescription Drug - Generic

$0

—

70010078628

METHYLERGONOVINE 0.2 MG TABLET

Prescription Drug - Generic

$6

—

70015

Contrast x-ray of brain

Radiology

$160

—

70030

X-ray eye for foreign body

Radiology

$33

—

70069000801

EPINASTINE HCL 0.05% EYE DROPS

Prescription Drug - Generic

$14

—

70069001825

ACETYLCYSTEINE 10% VIAL (NOT FOR INJECTION)

Prescription Drug - Generic

$2

—

70069002003

ACETYLCYSTEINE 20% VIAL (NOT FOR INJECTION)

Prescription Drug - Generic

$1

—

70069002510

DEXAMETHASONE 100 MG/10 ML VL

Prescription Drug - Generic

$1

—

70069003003

HALOPERIDOL DEC 50 MG/ML AMPUL

Prescription Drug - Generic

$18

—

70069003105

HALOPERIDOL DEC 100 MG/ML AMP

Prescription Drug - Generic

$33

—

70069004401

CLONIDINE HCL ER 0.1 MG TABLET

Prescription Drug - Generic

$0

—

70069007201

NALOXONE 4 MG/10 ML VIAL

Prescription Drug - Generic

$4

—

70069012101

TROPICAMIDE 1% EYE DROPS

Prescription Drug - Generic

$0

—

70069013101

TOBRAMYCIN 0.3% EYE DROP

Prescription Drug - Generic

$1

—

70069017210

CYANOCOBALAMIN 1,000 MCG/ML

Prescription Drug - Generic

$1

—

70069018101

PILOCARPINE 1% EYE DROPS

Prescription Drug - Generic

$3

—

70069019101

PILOCARPINE 2% EYE DROPS

Prescription Drug - Generic

$4

—

70069020101

PILOCARPINE 4% EYE DROPS

Prescription Drug - Generic

$3

—

70069031101

POLYMYXIN B-TMP EYE DROPS

Prescription Drug - Generic

$0

—

70069042101

LATANOPROST 0.005% EYE DROPS

Prescription Drug - Generic

$2

—

70069058301

ATROPINE 1% EYE DROP

Prescription Drug - Generic

$4

—

70069058701

TRAVOPROST 0.004% EYE DROP

Prescription Drug - Generic

$10

—

70069069601

TIMOLOL 0.5% EYE DROPS

Prescription Drug - Generic

$21

—

70069082001

HYDROXYUREA 500 MG CAPSULE

Prescription Drug - Generic

$0

—

70100

X-ray exam of jaw <4views

Radiology

$40

—

70110

X-ray exam of jaw 4/> views

Radiology

$43

—

70120

X-ray exam of mastoids

Radiology

$39

—

70121157301

METHYLPREDNISOLONE 40 MG/ML VL

Prescription Drug - Generic

$8

—

70121157401

METHYLPREDNISOLONE 80 MG/ML VL

Prescription Drug - Generic

$12

—

70121160901

METHYLPREDNISOLONE 400 MG/10 ML

Prescription Drug - Generic

$6

—

70121161001

METHYLPREDNISOLONE 400 MG/5 ML

Prescription Drug - Generic

$13

—

70121168601

EXENATIDE 10 MCG DOSE PEN INJ

Prescription Drug - Generic

$300

—

70130

X-ray exam of mastoids

Radiology

$61

—

70134

X-ray exam of middle ear

Radiology

$61

—

70140

X-ray exam of facial bones

Radiology

$32

—

70150

X-ray exam of facial bones

Radiology

$47

—

70160

X-ray exam of nasal bones

Radiology

$37

—

70165000530

ADZENYS XR-ODT 3.1 MG TABLET

Prescription Drug - Brand

$19

—

70165001030

ADZENYS XR-ODT 6.3 MG TABLET

Prescription Drug - Brand

$19

—

My Cost List