Medical Procedure Costs

75907003901

LIOTHYRONINE SOD 5 MCG TAB

Prescription Drug - Generic

$0

—

75907004301

TRIMETHOPRIM 100 MG TABLET

Prescription Drug - Generic

$1

—

75907004401

DILTIAZEM 12HR ER 60 MG CAP

Prescription Drug - Generic

$2

—

75907004501

DILTIAZEM 12HR ER 90 MG CAP

Prescription Drug - Generic

$2

—

75907004601

DILTIAZEM 12HR ER 120 MG CAP

Prescription Drug - Generic

$2

—

75907004881

CYCLOSPORINE MODIFIED 100 MG

Prescription Drug - Generic

$1

—

75907004901

METHYLPHENIDATE ER(LA) 10 MG CP

Prescription Drug - Generic

$3

—

75907005001

METHYLPHENIDATE ER(LA) 20 MG CP

Prescription Drug - Generic

$2

—

75907005101

METHYLPHENIDATE ER(LA) 30 MG CP

Prescription Drug - Generic

$2

—

75907005201

METHYLPHENIDATE ER(LA) 40 MG CP

Prescription Drug - Generic

$2

—

75907005330

METHYLPHENIDATE ER(LA) 60 MG CP

Prescription Drug - Generic

$11

—

75907005860

TAMOXIFEN 10 MG TABLET

Prescription Drug - Generic

$0

—

75907005930

TAMOXIFEN 20 MG TABLET

Prescription Drug - Generic

$0

—

75907006060

NYSTATIN 100,000 UNIT/GM POWD

Prescription Drug - Generic

$0

—

75907006905

NORTRIPTYLINE HCL 10 MG CAP

Prescription Drug - Generic

$0

—

75907007005

NORTRIPTYLINE HCL 25 MG CAP

Prescription Drug - Generic

$0

—

75907007105

NORTRIPTYLINE HCL 50 MG CAP

Prescription Drug - Generic

$0

—

75907007201

NORTRIPTYLINE HCL 75 MG CAP

Prescription Drug - Generic

$0

—

75907007432

CAMILA 0.35 MG TABLET

Prescription Drug - Generic

$0

—

75907007532

ERRIN 0.35 MG TABLET

Prescription Drug - Generic

$0

—

75907007601

ERYTHROMYCIN DR 250 MG CAP

Prescription Drug - Generic

$6

—

75907008162

MICROGESTIN FE 1.5-30 TAB

Prescription Drug - Generic

$0

—

75907008262

MICROGESTIN FE 1-20 TABLET

Prescription Drug - Generic

$0

—

75907008363

MICROGESTIN 21 1.5-30 TAB

Prescription Drug - Generic

$0

—

75907008463

MICROGESTIN 21 1-20 TABLET

Prescription Drug - Generic

$0

—

75907008532

NECON 0.5-35-28 TABLET

Prescription Drug - Generic

$0

—

75907008632

TILIA FE 28 TABLET

Prescription Drug - Generic

$1

—

75907008762

ZOVIA 1-35 TABLET

Prescription Drug - Generic

$0

—

75907008813

HALOETTE VAGINAL RING

Prescription Drug - Generic

$51

—

75907009162

AZURETTE 28 DAY TABLET

Prescription Drug - Generic

$0

—

75907009540

FLUOROURACIL 5% CREAM

Prescription Drug - Generic

$1

—

75907012907

PHENYLEPHRINE 2.5% EYE DROP

Prescription Drug - Generic

$9

—

75907016721

IVERMECTIN 3 MG TABLET

Prescription Drug - Generic

$2

—

75907020716

BROMPHEN-PSE-DM 2-30-10 MG/5 ML

Prescription Drug - Generic

$0

—

75907030930

TRANEXAMIC ACID 650 MG TABLET

Prescription Drug - Generic

$1

—

75907031030

SERTRALINE 150 MG CAPSULE

Prescription Drug - Generic

$5

—

75907031130

SERTRALINE 200 MG CAPSULE

Prescription Drug - Generic

$5

—

75984

Xray control catheter change

Radiology

$94

—

75987001003

DUEXIS 800-26.6 MG TABLET

Prescription Drug - Brand

$26

—

75987002001

RAYOS DR 1 MG TABLET

Prescription Drug - Brand

$88

—

75987002101

RAYOS DR 2 MG TABLET

Prescription Drug - Brand

$88

—

75987002201

RAYOS DR 5 MG TABLET

Prescription Drug - Brand

$88

—

75987003004

VIMOVO DR 500-20 MG TABLET

Prescription Drug - Brand

$40

—

75987003104

VIMOVO DR 375-20 MG TABLET

Prescription Drug - Brand

$36

—

75987004005

PENNSAID 2% PUMP

Prescription Drug - Brand

$21

—

75989

Abscess drainage under x-ray

Radiology

$113

—

76000

Fluoroscopy <1 hr phys/qhp

Radiology

$44

—

76010

X-ray nose to rectum

Radiology

$29

—

76014

Mr sfty implt&/fb asmt stf 1

Radiology

$11

—

76015

Mr sfty mplt&/fb asmt stf ea

Radiology

$53

—

My Cost List