Medical Procedure Costs

71930004812

POTASSIUM CITRATE ER 5 MEQ TAB

Prescription Drug - Generic

$0

—

71930004912

POTASSIUM CITRATE ER 10 MEQ TB

Prescription Drug - Generic

$0

—

71930005012

POTASSIUM CITRATE ER 15 MEQ TB

Prescription Drug - Generic

$0

—

71930005452

ACETAMINOPHEN-COD #2 TABLET

Prescription Drug - Generic

$0

—

71930005552

ACETAMINOPHEN-COD #3 TABLET

Prescription Drug - Generic

$0

—

71930005652

ACETAMINOPHEN-COD #4 TABLET

Prescription Drug - Generic

$0

—

71930007212

CARBAMAZEPINE ER 100 MG TABLET

Prescription Drug - Generic

$0

—

71930007312

CARBAMAZEPINE ER 200 MG TABLET

Prescription Drug - Generic

$0

—

71930007412

CARBAMAZEPINE ER 400 MG TABLET

Prescription Drug - Generic

$1

—

71930007850

HYDROCORTISONE 5 MG TABLET

Prescription Drug - Generic

$0

—

71930007912

HYDROCORTISONE 10 MG TABLET

Prescription Drug - Generic

$0

—

71930008012

HYDROCORTISONE 20 MG TABLET

Prescription Drug - Generic

$0

—

72020

X-ray exam of spine 1 view

Radiology

$24

—

72040

X-ray exam neck spine 2-3 vw

Radiology

$40

—

72050

X-ray exam neck spine 4/5vws

Radiology

$55

—

72052

X-ray exam neck spine 6/>vws

Radiology

$63

—

72060011040

CAPLYTA 10.5 MG CAPSULE

Prescription Drug - Brand

$57

—

72060012140

CAPLYTA 21 MG CAPSULE

Prescription Drug - Brand

$57

—

72060014240

CAPLYTA 42 MG CAPSULE

Prescription Drug - Brand

$57

—

72065012012

GVOKE HYPOPEN 2PK 0.5 MG/0.1 ML

Prescription Drug - Brand

$3,205

—

72065012111

GVOKE HYPOPEN 1-PK 1 MG/0.2 ML

Prescription Drug - Brand

$1,602

—

72065012112

GVOKE HYPOPEN 2-PK 1 MG/0.2 ML

Prescription Drug - Brand

$1,600

—

72065013111

GVOKE PFS 1-PK 1 MG/0.2 ML SYR

Prescription Drug - Brand

$1,604

—

72065013112

GVOKE PFS 2-PK 1 MG/0.2 ML SYR

Prescription Drug - Brand

$1,607

—

72065014011

GVOKE 1 MG/0.2 ML KIT

Prescription Drug - Brand

$1,604

—

72065014111

GVOKE 1 MG/0.2 ML VIAL

Prescription Drug - Brand

$1,604

—

72070

X-ray exam thorac spine 2vws

Radiology

$33

—

72072

X-ray exam thorac spine 3vws

Radiology

$39

—

72074

X-ray exam thorac spine4/>vw

Radiology

$44

—

72080

X-ray exam thoracolmb 2/> vw

Radiology

$35

—

72081

X-ray exam entire spi 1 vw

Radiology

$44

—

72082

X-ray exam entire spi 2/3 vw

Radiology

$72

—

72083

X-ray exam entire spi 4/5 vw

Radiology

$80

—

72084

X-ray exam entire spi 6/> vw

Radiology

$99

—

72100

X-ray exam l-s spine 2/3 vws

Radiology

$40

—

72110

X-ray exam l-2 spine 4/>vws

Radiology

$53

—

72114

X-ray exam l-s spine bending

Radiology

$62

—

72120

X-ray bend only l-s spine

Radiology

$42

—

72125

Ct neck spine w/o dye

Radiology

$131

—

72126

Ct neck spine w/dye

Radiology

$168

—

72127

Ct neck spine w/o & w/dye

Radiology

$196

—

72128

Ct chest spine w/o dye

Radiology

$130

—

72129

Ct chest spine w/dye

Radiology

$169

—

72130

Ct chest spine w/o & w/dye

Radiology

$198

—

72131

Ct lumbar spine w/o dye

Radiology

$130

—

72132

Ct lumbar spine w/dye

Radiology

$169

—

72133

Ct lumbar spine w/o & w/dye

Radiology

$197

—

72141

Mri neck spine w/o dye

Radiology

$191

—

72142

Mri neck spine w/dye

Radiology

$274

—

72146

Mri chest spine w/o dye

Radiology

$190

—

My Cost List