Medical Procedure Costs

15127097324

SB ALLERGY & COLD PE CAPLET

Prescription Drug - Generic

$0

—

15127097412

SB SEVERE COLD PE CAPLET

Prescription Drug - Generic

$0

—

15127097804

SB CHILD IBUPROFEN 100 MG/5 ML

Prescription Drug - Generic

$0

—

15127099424

SB PAIN RELIEVER 500 MG GELCAP

Prescription Drug - Generic

$0

—

15130

Drm agrft t/a/l 1st 100 sqcm

Surgery - Integumentary

$550

—

15131

Drm agrft t/a/l ea addl

Surgery - Integumentary

$75

—

15135

Drm agrft f/s/n/h/f/g/m 1st

Surgery - Integumentary

$674

—

15136

Drm agrft f/s/n/h/f/g/m ea

Surgery - Integumentary

$75

—

15150

Tis cltr skn agrft t/a/l 1st

Surgery - Integumentary

$617

—

15151

Tis cltr skn agrft t/a/l add

Surgery - Integumentary

$98

—

15152

Tis cltr skn agrft t/a/l ea

Surgery - Integumentary

$123

—

15155

Tis cltr agrft f/s/n/h/f/g 1

Surgery - Integumentary

$657

—

15156

Tis clt agrft f/s/n/h/f/g ad

Surgery - Integumentary

$135

—

15157

Tis clt agrft f/s/n/h/f/g ea

Surgery - Integumentary

$148

—

15200

Fth/gft fr trnk 20 sq cm/<

Surgery - Integumentary

$605

—

15201

Fth/gft fr trnk each addl

Surgery - Integumentary

$65

—

15220

Fth/gft fr s/a/l 20 sq cm/<

Surgery - Integumentary

$538

—

15221

Fth/gft fr s/a/l each addl

Surgery - Integumentary

$58

—

15240

Fth/gft f/c/c/m/n/ax/g/h/f20

Surgery - Integumentary

$698

—

15241

Fth/gft f/c/c/m/n/a/g/h/f ea

Surgery - Integumentary

$90

—

15260

Fth/gft fr n/e/e/l 20 sqcm/<

Surgery - Integumentary

$727

—

15261

Fth/gft fr n/e/e/l each addl

Surgery - Integumentary

$113

—

15271

Skin sub graft trnk/arm/leg

Surgery - Integumentary

$75

—

15272

Skin sub graft t/a/l add-on

Surgery - Integumentary

$15

—

15273

Skin sub grft t/arm/lg child

Surgery - Integumentary

$172

—

15274

Skn sub grft t/a/l child add

Surgery - Integumentary

$39

—

15275

Skin sub graft face/nk/hf/g

Surgery - Integumentary

$84

—

15276

Skin sub graft f/n/hf/g addl

Surgery - Integumentary

$22

—

15277

Skn sub grft f/n/hf/g child

Surgery - Integumentary

$197

—

15278

Skn sub grft f/n/hf/g ch add

Surgery - Integumentary

$49

—

15370003110

RU-HIST-D TABLET

Prescription Drug - Generic

$0

—

15370010430

QUFLORA PED 0.5 MG CHEW TAB

Prescription Drug - Brand

$6

—

15370010530

QUFLORA PED 1 MG CHEW TAB

Prescription Drug - Brand

$6

—

15370013010

RYVENT 6 MG TABLET

Prescription Drug - Brand

$8

—

15370015004

RYCLORA 2 MG/5 ML SOLUTION

Prescription Drug - Brand

$3

—

15370018060

LOFENA 25 MG TABLET

Prescription Drug - Generic

$4

—

15370025030

TRISTART DHA SOFTGEL

Prescription Drug - Brand

$9

—

15370030560

POKONZA 10 MEQ PACKET

Prescription Drug - Brand

$28

—

15570

Skin pedicle flap trunk

Surgery - Integumentary

$673

—

15572

Skin pedicle flap arms/legs

Surgery - Integumentary

$670

—

15574

Pedcle fh/ch/ch/m/n/ax/g/h/f

Surgery - Integumentary

$640

—

15576

Pedicle e/n/e/l/ntroral

Surgery - Integumentary

$563

—

15584010101

ATRIPLA TABLET

Prescription Drug - Brand

$97

—

15600

Delay flap trunk

Surgery - Integumentary

$213

—

15610

Delay flap arms/legs

Surgery - Integumentary

$235

—

15620

Delay flap f/c/c/n/ax/g/h/f

Surgery - Integumentary

$305

—

15630

Delay flap eye/nos/ear/lip

Surgery - Integumentary

$311

—

15650

Transfer skin pedicle flap

Surgery - Integumentary

$383

—

15730

Mdfc flap w/prsrv vasc pedcl

Surgery - Integumentary

$782

—

15731

Forehead flap w/vasc pedicle

Surgery - Integumentary

$877

—

My Cost List