Medical Procedure Costs

73030

X-ray exam of shoulder

Radiology

$36

—

73040

Contrast x-ray of shoulder

Radiology

$135

—

73043000502

CYCLOSPORINE 0.05% EYE EMULSION

Prescription Drug - Generic

$1

—

73043001214

TEMOZOLOMIDE 20 MG CAPSULE

Prescription Drug - Generic

$2

—

73043001314

TEMOZOLOMIDE 100 MG CAPSULE

Prescription Drug - Generic

$10

—

73043001605

TEMOZOLOMIDE 250 MG CAPSULE

Prescription Drug - Generic

$21

—

73050

X-ray exam of shoulders

Radiology

$30

—

73059000160

ACCRUFER 30 MG CAPSULE

Prescription Drug - Brand

$10

—

73060

X-ray exam of humerus

Radiology

$32

—

73070

X-ray exam of elbow

Radiology

$29

—

73070010011

INSULIN ASPART 100 UNIT/ML VL

Prescription Drug - Generic

$7

—

73070010215

INSULIN ASPART PENFILL 100 UNIT/ML CARTRIDGE

Prescription Drug - Generic

$9

—

73070010315

INSULIN ASPART FLEXPEN 100 UNIT/ML PEN

Prescription Drug - Generic

$9

—

73070020011

INSULIN ASPART PROTAMINE-INSULIN ASPART MIX 70-30 VIAL

Prescription Drug - Generic

$7

—

73070020315

INSULIN ASPART PROTAMINE-INSULIN ASPART MIX 70-30 FLEXPEN

Prescription Drug - Generic

$9

—

73070040011

INSULIN DEGLUDEC 100 UNIT/ML VIAL

Prescription Drug - Generic

$11

—

73070040315

INSULIN DEGLUDEC FLEXTOUCH 100 UNIT/ML PEN

Prescription Drug - Generic

$11

—

73070050315

INSULIN DEGLUDEC FLEXTOUCH 200 UNIT/ML PEN

Prescription Drug - Generic

$23

—

73080

X-ray exam of elbow

Radiology

$33

—

73085

Contrast x-ray of elbow

Radiology

$96

—

73090

X-ray exam of forearm

Radiology

$29

—

73092

X-ray exam of arm infant

Radiology

$31

—

73100

X-ray exam of wrist

Radiology

$34

—

73110

X-ray exam of wrist

Radiology

$43

—

73115

Contrast x-ray of wrist

Radiology

$133

—

73120

X-ray exam of hand

Radiology

$31

—

73130

X-ray exam of hand

Radiology

$38

—

73140

X-ray exam of finger(s)

Radiology

$39

—

73154005060

IBSRELA 50 MG TABLET

Prescription Drug - Brand

$33

—

73200

Ct upper extremity w/o dye

Radiology

$161

—

73201

Ct upper extremity w/dye

Radiology

$199

—

73202

Ct uppr extremity w/o&w/dye

Radiology

$246

—

73206

Ct angio upr extrm w/o&w/dye

Radiology

$296

—

73218

Mri upper extremity w/o dye

Radiology

$303

—

73219

Mri upper extremity w/dye

Radiology

$330

—

73220

Mri uppr extremity w/o&w/dye

Radiology

$407

—

73221

Mri joint upr extrem w/o dye

Radiology

$205

—

73222

Mri joint upr extrem w/dye

Radiology

$313

—

73223

Mri joint upr extr w/o&w/dye

Radiology

$383

—

73225

Mr angio upr extr w/o&w/dye

Radiology

$324

—

73289006302

MOTPOLY XR 100 MG CAPSULE

Prescription Drug - Brand

$21

—

73289006402

MOTPOLY XR 150 MG CAPSULE

Prescription Drug - Brand

$21

—

73289006502

MOTPOLY XR 200 MG CAPSULE

Prescription Drug - Brand

$21

—

73302045601

ELLA 30 MG TABLET

Prescription Drug - Brand

$37

—

73336007590

GEMTESA 75 MG TABLET

Prescription Drug - Brand

$16

—

73352010201

FENOFIBRATE 120 MG TABLET

Prescription Drug - Generic

$16

—

73352010316

BACLOFEN 5 MG/5 ML SOLUTION

Prescription Drug - Generic

$1

—

73352069310

EVEXITHROID 15 MG TABLET

Prescription Drug - Generic

$1

—

73352069410

EVEXITHROID 30 MG TABLET

Prescription Drug - Generic

$1

—

73352069610

EVEXITHROID 60 MG TABLET

Prescription Drug - Generic

$1

—

My Cost List