Medical Procedure Costs

70515062501

PRILOSEC DR 2.5 MG SUSPENSION

Prescription Drug - Brand

$15

—

70515070101

OMNARIS 50 MCG NASAL SPRAY

Prescription Drug - Brand

$23

—

70515071101

ALVESCO 80 MCG INHALER

Prescription Drug - Brand

$43

—

70515071201

ALVESCO 160 MCG INHALER

Prescription Drug - Brand

$43

—

70515073760

ZETONNA 37 MCG NASAL SPRAY

Prescription Drug - Brand

$34

—

70539000102

TYMLOS 80 MCG DOSE PEN INJECTR

Prescription Drug - Brand

$1,745

—

70540

Mri orbit/face/neck w/o dye

Radiology

$224

—

70542

Mri orbit/face/neck w/dye

Radiology

$267

—

70543

Mri orbt/fac/nck w/o &w/dye

Radiology

$337

—

70544

Mr angiography head w/o dye

Radiology

$215

—

70545

Mr angiography head w/dye

Radiology

$226

—

70546

Mr angiograph head w/o&w/dye

Radiology

$328

—

70547

Mr angiography neck w/o dye

Radiology

$215

—

70548

Mr angiography neck w/dye

Radiology

$246

—

70549

Mr angiograph neck w/o&w/dye

Radiology

$343

—

70551

Mri brain stem w/o dye

Radiology

$195

—

70552

Mri brain stem w/dye

Radiology

$269

—

70553

Mri brain stem w/o & w/dye

Radiology

$317

—

70554

Fmri brain by tech

Radiology

$378

—

70564080260

MYTESI 125 MG DR TABLET

Prescription Drug - Brand

$36

—

70594002309

COLISTIMETHATE 150 MG VIAL

Prescription Drug - Generic

$16

—

70594006802

SUMATRIPTAN 6 MG/0.5 ML VIAL

Prescription Drug - Generic

$15

—

70677000101

SM NASAL DECONGEST ER 120 MG

Prescription Drug - Generic

$0

—

70677000201

SM ALLERGY RELIEF 25 MG CAP

Prescription Drug - Generic

$0

—

70677000202

SM ALLERGY (DIPHEN) 25 MG CAP

Prescription Drug - Generic

$0

—

70677000301

SM ALLERGY (DIPHEN) 25 MG TAB

Prescription Drug - Generic

$0

—

70677000401

SM ALLERGY 4 MG TABLET

Prescription Drug - Generic

$0

—

70677000503

SM NASAL DECONGEST 30 MG TAB

Prescription Drug - Generic

$0

—

70677001301

SM TRIPLE ANTIBIOTIC OINTMENT

Prescription Drug - Generic

$0

—

70677001603

SM ESOMEPRAZOLE MAG DR 20 MG

Prescription Drug - Generic

$0

—

70677001801

SM ARTHRIT PAIN RLF ER 650 MG

Prescription Drug - Generic

$0

—

70677002101

SM STAY AWAKE 200 MG TABLET

Prescription Drug - Generic

$0

—

70677002201

SM MOTION SICKNESS 50 MG TAB

Prescription Drug - Generic

$0

—

70677002401

SM NIGHTTIME SLEEP 25 MG CPLT

Prescription Drug - Generic

$0

—

70677002601

SM MOTION SICKNESS 25 MG TAB

Prescription Drug - Generic

$0

—

70677002901

SM CHILD ALLERGY 5 MG/5 ML SOL

Prescription Drug - Generic

$0

—

70677003001

SM NICOTINE 7 MG/24HR PATCH

Prescription Drug - Generic

$2

—

70677003101

SM NICOTINE 14 MG/24HR PATCH

Prescription Drug - Generic

$2

—

70677003201

SM NICOTINE 21 MG/24HR PATCH

Prescription Drug - Generic

$2

—

70677003402

SM STOOL SOFTENER 100 MG SFTGL

Prescription Drug - Generic

$0

—

70677003601

SM LORATADINE-D 12 HOUR TABLET

Prescription Drug - Generic

$1

—

70677003701

SM DAY TIME COLD-FLU RLF SFTGL

Prescription Drug - Generic

$0

—

70677003801

SM EPSOM SALT GRANULES

Prescription Drug - Generic

$0

—

70677004201

SM SENNA-S TABLET

Prescription Drug - Generic

$0

—

70677004601

SM IBUPROFEN 200 MG SOFTGEL

Prescription Drug - Generic

$0

—

70677004801

SM TUSSIN DM COUGH-CHEST CONG

Prescription Drug - Generic

$0

—

70677005001

SM MUCUS-ER MAX 1,200 MG TAB

Prescription Drug - Generic

$0

—

70677005301

SM MAGNESIUM CITRATE SOLUTION

Prescription Drug - Generic

$0

—

70677005401

SM ANTI-DIARRHEAL 1 MG/7.5 ML

Prescription Drug - Generic

$0

—

70677005501

SM MUCUS RELIEF ER 600 MG TAB

Prescription Drug - Generic

$0

—

My Cost List