Medical Procedure Costs

72205018301

BORTEZOMIB 3.5 MG VIAL

Prescription Drug - Generic

$43

—

72205020090

ROFLUMILAST 500 MCG TABLET

Prescription Drug - Generic

$0

—

72205020132

ROFLUMILAST 250 MCG TABLET

Prescription Drug - Generic

$2

—

72205020260

DABIGATRAN ETEXILATE 75 MG CAP

Prescription Drug - Generic

$1

—

72205020360

DABIGATRAN ETEXILATE 110 MG CP

Prescription Drug - Generic

$1

—

72205020460

DABIGATRAN ETEXILATE 150 MG CP

Prescription Drug - Generic

$1

—

72205021830

PRUCALOPRIDE 1 MG TABLET

Prescription Drug - Generic

$1

—

72205021930

PRUCALOPRIDE 2 MG TABLET

Prescription Drug - Generic

$1

—

72205022130

PERAMPANEL 2 MG TABLET

Prescription Drug - Generic

$14

—

72205022230

PERAMPANEL 4 MG TABLET

Prescription Drug - Generic

$26

—

72205022330

PERAMPANEL 6 MG TABLET

Prescription Drug - Generic

$27

—

72205022430

PERAMPANEL 8 MG TABLET

Prescription Drug - Generic

$29

—

72205022530

PERAMPANEL 10 MG TABLET

Prescription Drug - Generic

$29

—

72205022630

PERAMPANEL 12 MG TABLET

Prescription Drug - Generic

$31

—

72205024643

LOFEXIDINE 0.18 MG TABLET

Prescription Drug - Generic

$10

—

72205033660

IVABRADINE HCL 5 MG TABLET

Prescription Drug - Generic

$1

—

72205033760

IVABRADINE HCL 7.5 MG TABLET

Prescription Drug - Generic

$1

—

72220

X-ray exam sacrum tailbone

Radiology

$32

—

72240

Myelography neck spine

Radiology

$112

—

72241001103

RIVASTIGMINE 1.5 MG CAPSULE

Prescription Drug - Generic

$0

—

72241001203

RIVASTIGMINE 3 MG CAPSULE

Prescription Drug - Generic

$0

—

72241001303

RIVASTIGMINE 4.5 MG CAPSULE

Prescription Drug - Generic

$0

—

72241001403

RIVASTIGMINE 6 MG CAPSULE

Prescription Drug - Generic

$0

—

72241001522

TELMISARTAN 20 MG TABLET

Prescription Drug - Generic

$0

—

72241001622

TELMISARTAN 40 MG TABLET

Prescription Drug - Generic

$0

—

72241001722

TELMISARTAN 80 MG TABLET

Prescription Drug - Generic

$0

—

72241002503

CELECOXIB 400 MG CAPSULE

Prescription Drug - Generic

$0

—

72241002922

PAROXETINE ER 12.5 MG TABLET

Prescription Drug - Generic

$0

—

72241003022

PAROXETINE ER 25 MG TABLET

Prescription Drug - Generic

$0

—

72241003122

PAROXETINE ER 37.5 MG TABLET

Prescription Drug - Generic

$0

—

72241003805

GLYBURIDE 1.25 MG TABLET

Prescription Drug - Generic

$0

—

72241003911

GLYBURIDE 2.5 MG TABLET

Prescription Drug - Generic

$0

—

72241004011

GLYBURIDE 5 MG TABLET

Prescription Drug - Generic

$0

—

72241005011

FOLIC ACID 1 MG TABLET

Prescription Drug - Generic

$0

—

72252050505

VALTOCO 5 MG NASAL SPRAY

Prescription Drug - Brand

$366

—

72252051005

VALTOCO 10 MG NASAL SPRAY

Prescription Drug - Brand

$366

—

72252051510

VALTOCO 15 MG NASAL SPRAY

Prescription Drug - Brand

$366

—

72252052010

VALTOCO 20 MG NASAL SPRAY

Prescription Drug - Brand

$365

—

72255

Myelography thoracic spine

Radiology

$104

—

72265

Myelography l-s spine

Radiology

$110

—

72266012401

ONDANSETRON 40 MG/20 ML VIAL

Prescription Drug - Generic

$0

—

72266014001

BIMATOPROST 0.03% EYE DROPS

Prescription Drug - Generic

$7

—

72266014101

AZELASTINE HCL 0.05% DROPS

Prescription Drug - Generic

$1

—

72266014201

BROMFENAC SODIUM 0.09% EYE DRP

Prescription Drug - Generic

$16

—

72266015801

MOXIFLOXACIN 0.5% EYE DROPS

Prescription Drug - Generic

$2

—

72266015910

ERTAPENEM 1 GRAM VIAL

Prescription Drug - Generic

$27

—

72266016042

ZIPRASIDONE 20 MG/ML VIAL

Prescription Drug - Generic

$24

—

72270

Myelogphy 2/> spine regions

Radiology

$134

—

72285

Discography cerv/thor spine

Radiology

$145

—

72295

X-ray of lower spine disk

Radiology

$122

—

My Cost List