Medical Procedure Costs

71288080651

ZOLEDRONIC ACID 5 MG/100 ML

Prescription Drug - Generic

$0

—

71321070016

BRANTUSSIN DM 2-15-7.5 MG/5 ML

Prescription Drug - Generic

$0

—

71376020103

JORNAY PM 20 MG CAPSULE

Prescription Drug - Brand

$15

—

71376020203

JORNAY PM 40 MG CAPSULE

Prescription Drug - Brand

$15

—

71376020303

JORNAY PM 60 MG CAPSULE

Prescription Drug - Brand

$15

—

71376020403

JORNAY PM 80 MG CAPSULE

Prescription Drug - Brand

$15

—

71376020503

JORNAY PM 100 MG CAPSULE

Prescription Drug - Brand

$15

—

71550

Mri chest w/o dye

Radiology

$333

—

71551

Mri chest w/dye

Radiology

$371

—

71552

Mri chest w/o & w/dye

Radiology

$466

—

71555

Mri angio chest w or w/o dye

Radiology

$334

—

71571012128

INVELTYS 1% EYE DROP

Prescription Drug - Brand

$103

—

71571033383

EYSUVIS 0.25% EYE DROPS

Prescription Drug - Brand

$62

—

71626010106

ZOLMITRIPTAN 2.5 MG TABLET

Prescription Drug - Generic

$1

—

71626010203

ZOLMITRIPTAN 5 MG TABLET

Prescription Drug - Generic

$1

—

71656003060

ERYTHROMYCIN 2% SOLUTION

Prescription Drug - Generic

$0

—

71656004060

TRIAMCINOLONE 0.1% LOTION

Prescription Drug - Generic

$0

—

71656004280

TRIAMCINOLONE 0.1% CREAM

Prescription Drug - Generic

$0

—

71656006410

HYDROCORTISONE 1%-ACETIC ACID 2% EAR DROP

Prescription Drug - Generic

$6

—

71656006675

LIKMEZ 500 MG/5 ML SUSPENSION

Prescription Drug - Brand

$3

—

71656008904

FLUOXETINE 20 MG/5 ML SOLUTION

Prescription Drug - Generic

$0

—

71671010011

TWIRLA 120-30 MCG/DAY PATCH

Prescription Drug - Brand

$67

—

71699002530

XCOPRI 25 MG TABLET

Prescription Drug - Brand

$40

—

71699005030

XCOPRI 50 MG TABLET

Prescription Drug - Brand

$40

—

71699010030

XCOPRI 100 MG TABLET

Prescription Drug - Brand

$40

—

71699010356

XCOPRI 350 MG DAILY DOSE PACK

Prescription Drug - Brand

$43

—

71699010456

XCOPRI 250 MG DAILY DOSE PACK

Prescription Drug - Brand

$21

—

71699015030

XCOPRI 150 MG TABLET

Prescription Drug - Brand

$40

—

71699020030

XCOPRI 200 MG TABLET

Prescription Drug - Brand

$40

—

71699020128

XCOPRI 12.5-25 MG TITRATION PK

Prescription Drug - Brand

$4

—

71699020228

XCOPRI 50-100 MG TITRATION PAK

Prescription Drug - Brand

$43

—

71699020328

XCOPRI 150-200 MG TITRATION PK

Prescription Drug - Brand

$43

—

71770010560

SIKLOS 100 MG TABLET

Prescription Drug - Brand

$6

—

71770012030

SIKLOS 1,000 MG TABLET

Prescription Drug - Brand

$62

—

71776000110

FRESHKOTE EYE DROP

Prescription Drug - Brand

$3

—

71776010005

FLAREX 0.1% EYE DROPS

Prescription Drug - Brand

$24

—

71800003106

LUBRICANT 0.6% EYE DROP

Prescription Drug - Generic

$0

—

71800004409

BENZOYL PEROXIDE 5% LOTION

Prescription Drug - Generic

$0

—

71800004609

BENZOYL PEROXIDE 10% LOTION

Prescription Drug - Generic

$0

—

71858000504

TIROSINT 13 MCG CAPSULE

Prescription Drug - Brand

$4

—

71858001004

TIROSINT 25 MCG CAPSULE

Prescription Drug - Brand

$4

—

71858001204

TIROSINT 37.5 MCG CAPSULE

Prescription Drug - Brand

$5

—

71858001504

TIROSINT 50 MCG CAPSULE

Prescription Drug - Brand

$5

—

71858001704

TIROSINT 62.5 MCG CAPSULE

Prescription Drug - Brand

$5

—

71858002004

TIROSINT 75 MCG CAPSULE

Prescription Drug - Brand

$5

—

71858002504

TIROSINT 88 MCG CAPSULE

Prescription Drug - Brand

$4

—

71858003004

TIROSINT 100 MCG CAPSULE

Prescription Drug - Brand

$4

—

71858003504

TIROSINT 112 MCG CAPSULE

Prescription Drug - Brand

$4

—

71858004004

TIROSINT 125 MCG CAPSULE

Prescription Drug - Brand

$5

—

71858004504

TIROSINT 137 MCG CAPSULE

Prescription Drug - Brand

$4

—

My Cost List