Medical Procedure Costs

76016

Mr safety deter phys/qhp

Radiology

$72

—

76017

Mr sfty med physics xm cstmz

Radiology

$222

—

76018

Mr safety implant elec prepj

Radiology

$115

—

76019

Mr safety implt pos&/immoblj

Radiology

$153

—

76080

X-ray exam of fistula

Radiology

$59

—

76098

X-ray exam surgical specimen

Radiology

$43

—

76100

X-ray exam of body section

Radiology

$86

—

76120

Cine/video x-rays

Radiology

$114

—

76145

Med physic dos eval rad exps

Radiology

$1,039

—

76204001055

ALBUTEROL SUL 0.63 MG/3 ML SOL

Prescription Drug - Generic

$0

—

76204001155

ALBUTEROL SUL 1.25 MG/3 ML SOL

Prescription Drug - Generic

$0

—

76204002602

ARFORMOTEROL 15 MCG/2 ML SOLN

Prescription Drug - Generic

$1

—

76204002701

ALBUTEROL 2.5 MG/0.5 ML SOL

Prescription Drug - Generic

$1

—

76204002860

CROMOLYN 20 MG/2 ML NEB SOLN

Prescription Drug - Generic

$1

—

76204002956

TOBRAMYCIN 300 MG/5 ML AMPULE

Prescription Drug - Generic

$1

—

76204003002

FORMOTEROL 20 MCG/2 ML NEB VL

Prescription Drug - Generic

$2

—

76204010060

IPRATROPIUM BR 0.02% SOLN

Prescription Drug - Generic

$0

—

76204020060

ALBUTEROL 0.083% INHAL SOLN

Prescription Drug - Generic

$0

—

76204060060

IPRATROPIUM-ALBUTEROL 0.5-3(2.5) MG/3 ML

Prescription Drug - Generic

$0

—

76204070025

LEVALBUTEROL 0.31 MG/3 ML SOL

Prescription Drug - Generic

$0

—

76204080025

LEVALBUTEROL 0.63 MG/3 ML SOL

Prescription Drug - Generic

$0

—

76204090025

LEVALBUTEROL 1.25 MG/3 ML SOL

Prescription Drug - Generic

$0

—

76282010339

DICLOFENAC SODIUM 1% GEL

Prescription Drug - Generic

$0

—

76282020090

FOSINOPRIL SODIUM 10 MG TAB

Prescription Drug - Generic

$0

—

76282020190

FOSINOPRIL SODIUM 20 MG TAB

Prescription Drug - Generic

$0

—

76282020290

FOSINOPRIL SODIUM 40 MG TAB

Prescription Drug - Generic

$0

—

76282021290

SERTRALINE HCL 25 MG TABLET

Prescription Drug - Generic

$0

—

76282022560

GEMFIBROZIL 600 MG TABLET

Prescription Drug - Generic

$0

—

76282022601

ZONISAMIDE 25 MG CAPSULE

Prescription Drug - Generic

$0

—

76282022701

ZONISAMIDE 50 MG CAPSULE

Prescription Drug - Generic

$0

—

76282022801

ZONISAMIDE 100 MG CAPSULE

Prescription Drug - Generic

$0

—

76282025630

RALOXIFENE HCL 60 MG TABLET

Prescription Drug - Generic

$0

—

76282025705

NABUMETONE 500 MG TABLET

Prescription Drug - Generic

$0

—

76282025805

NABUMETONE 750 MG TABLET

Prescription Drug - Generic

$0

—

76282028160

TOPIRAMATE 200 MG TABLET

Prescription Drug - Generic

$0

—

76282028390

CYCLOBENZAPRINE 10 MG TABLET

Prescription Drug - Generic

$0

—

76282030290

ALFUZOSIN HCL ER 10 MG TABLET

Prescription Drug - Generic

$0

—

76282030910

HYDRALAZINE 10 MG TABLET

Prescription Drug - Generic

$0

—

76282031010

HYDRALAZINE 25 MG TABLET

Prescription Drug - Generic

$0

—

76282031110

HYDRALAZINE 50 MG TABLET

Prescription Drug - Generic

$0

—

76282031201

HYDRALAZINE 100 MG TABLET

Prescription Drug - Generic

$0

—

76282032710

WARFARIN SODIUM 1 MG TABLET

Prescription Drug - Generic

$0

—

76282032810

WARFARIN SODIUM 2 MG TABLET

Prescription Drug - Generic

$0

—

76282032910

WARFARIN SODIUM 2.5 MG TABLET

Prescription Drug - Generic

$0

—

76282033010

WARFARIN SODIUM 3 MG TABLET

Prescription Drug - Generic

$0

—

76282033110

WARFARIN SODIUM 4 MG TABLET

Prescription Drug - Generic

$0

—

76282033210

WARFARIN SODIUM 5 MG TABLET

Prescription Drug - Generic

$0

—

76282033310

WARFARIN SODIUM 6 MG TABLET

Prescription Drug - Generic

$0

—

76282033401

WARFARIN SODIUM 7.5 MG TABLET

Prescription Drug - Generic

$0

—

76282033501

WARFARIN SODIUM 10 MG TABLET

Prescription Drug - Generic

$0

—

My Cost List