Medical Procedure Costs

70436001704

OLMSRTN-AMLDPN-HYDROCHLOROTHIAZIDE 40-10-12.5

Prescription Drug - Generic

$1

—

70436001804

OLMSRTN-AMLDPN-HYDROCHLOROTHIAZIDE 40-10-25 MG

Prescription Drug - Generic

$1

—

70436005404

MEMANTINE HCL ER 7 MG CAPSULE

Prescription Drug - Generic

$0

—

70436005506

MEMANTINE HCL ER 14 MG CAPSULE

Prescription Drug - Generic

$0

—

70436005604

MEMANTINE HCL ER 21 MG CAPSULE

Prescription Drug - Generic

$0

—

70436005706

MEMANTINE HCL ER 28 MG CAPSULE

Prescription Drug - Generic

$0

—

70436010109

TETRABENAZINE 12.5 MG TABLET

Prescription Drug - Generic

$1

—

70436010209

TETRABENAZINE 25 MG TABLET

Prescription Drug - Generic

$1

—

70436015542

PROMETHAZINE-DM 6.25-15 MG/5 ML SOLUTION

Prescription Drug - Generic

$0

—

70436015606

CILOSTAZOL 50 MG TABLET

Prescription Drug - Generic

$0

—

70436015706

CILOSTAZOL 100 MG TABLET

Prescription Drug - Generic

$0

—

70436016006

TOLTERODINE TART ER 2 MG CAP

Prescription Drug - Generic

$0

—

70436016106

TOLTERODINE TART ER 4 MG CAP

Prescription Drug - Generic

$0

—

70436017404

TROSPIUM CHLORIDE ER 60 MG CAP

Prescription Drug - Generic

$2

—

70436019102

DILTIAZEM 24H ER(XR) 120 MG CP

Prescription Drug - Generic

$0

—

70436019202

DILTIAZEM 24H ER(XR) 180 MG CP

Prescription Drug - Generic

$0

—

70436019302

DILTIAZEM 24H ER(XR) 240 MG CP

Prescription Drug - Generic

$1

—

70436019506

DILTIAZEM 24H ER(LA) 120 MG TB

Prescription Drug - Generic

$2

—

70436019606

DILTIAZEM 24H ER(LA) 180 MG TB

Prescription Drug - Generic

$1

—

70436019706

DILTIAZEM 24H ER(LA) 240 MG TB

Prescription Drug - Generic

$1

—

70436019806

DILTIAZEM 24H ER(LA) 300 MG TB

Prescription Drug - Generic

$2

—

70436019906

DILTIAZEM 24H ER(LA) 360 MG TB

Prescription Drug - Generic

$2

—

70436020006

DILTIAZEM 24H ER(LA) 420 MG TB

Prescription Drug - Generic

$2

—

70436022748

FLUCONAZOLE 40 MG/ML SUSP

Prescription Drug - Generic

$1

—

70450

Ct head/brain w/o dye

Radiology

$107

—

70460

Ct head/brain w/dye

Radiology

$148

—

70470

Ct head/brain w/o & w/dye

Radiology

$173

—

70471

Cta h&n c+ w/noncontrast img

Radiology

$377

—

70472

Ct cere prfu alys c+w/ct/cta

Radiology

$156

—

70473

Ct cere prfu aly c+wo ct/cta

Radiology

$241

—

70480

Ct orbit/ear/fossa w/o dye

Radiology

$158

—

70481

Ct orbit/ear/fossa w/dye

Radiology

$180

—

70482

Ct orbit/ear/fossa w/o&w/dye

Radiology

$209

—

70486

Ct maxillofacial w/o dye

Radiology

$128

—

70487

Ct maxillofacial w/dye

Radiology

$152

—

70488

Ct maxillofacial w/o & w/dye

Radiology

$184

—

70490

Ct soft tissue neck w/o dye

Radiology

$150

—

70491

Ct soft tissue neck w/dye

Radiology

$183

—

70492

Ct sft tsue nck w/o & w/dye

Radiology

$220

—

70496

Ct angiography head

Radiology

$274

—

70498

Ct angiography neck

Radiology

$274

—

70505010010

DOXYLAMINE-PYRIDOXINE 10-10 MG

Prescription Drug - Generic

$1

—

70512001610

CAPSIMIDE 0.025% PATCH

Prescription Drug - Generic

$1

—

70512010130

HYDROCORTISONE 1% CREAM

Prescription Drug - Generic

$0

—

70512052005

OLOPATADINE HCL 0.1% EYE DROP

Prescription Drug - Generic

$1

—

70512079010

KETOROLAC 0.5% OPHTH SOLUTION

Prescription Drug - Generic

$1

—

70512081005

DICLOFENAC 1.5% TOPICAL SOLN

Prescription Drug - Generic

$0

—

70512081230

LIDOCAINE 4% PATCH

Prescription Drug - Generic

$1

—

70512086008

CABERGOLINE 0.5 MG TABLET

Prescription Drug - Generic

$1

—

70515061001

PRILOSEC DR 10 MG SUSPENSION

Prescription Drug - Brand

$15

—

My Cost List