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Days | BS Description E | ICD | IOS BS | CPT | PACKAGE | Price | Center |
|---|---|---|---|---|---|---|---|
0 | GLYNASE ORAL TABLET 5 mg | 700933 | 547061620 | 0.82 | |||
0 | GONAL-F(R) SUBCUTANEOUS Prefilled syringe 300 | 700934 | 547014146 | 363 | |||
INTERN. UNIT (PEN ) | |||||||
0 | GONIOVISC OPHTHALMIC SOLUTION 2.5 % ( Non | 700935 | 1500 | 0.95 | |||
formulary ) Drop | |||||||
0 | GRACIAL(R) ORAL TABLET 10 mcg 22 Box | 700936 | 547014114 | 0.99 | |||
0 | GRIPPO(R) RECTAL SUPPOSITORY 200 mg | 700937 | 0.46 | ||||
0 | GRISOVIN(R) ORAL TABLET 125 mg | 700938 | 540021520 | 0.16 | |||
0 | GRISOVIN(R) ORAL TABLET 500 mg | 700939 | 540021520 | 0.63 | |||
0 | GUAPHAN(R) ORAL SYRUP 100 mg/5ml 100 Bottle | 700940 | 4.95 | ||||
0 | GUPISONE(R) ORAL TABLET 20 mg | 700941 | 547051430 | 0.31 | |||
0 | GUPISONE(R) ORAL TABLET 5 mg 20 Tab | 700942 | 547051420 | 0.31 |
GLYNASE ORAL TABLET 5 mg
0.82
GONAL-F(R) SUBCUTANEOUS Prefilled syringe 300
363
INTERN. UNIT (PEN )
GONIOVISC OPHTHALMIC SOLUTION 2.5 % ( Non
0.95
formulary ) Drop
GRACIAL(R) ORAL TABLET 10 mcg 22 Box
0.99
GRIPPO(R) RECTAL SUPPOSITORY 200 mg
0.46
GRISOVIN(R) ORAL TABLET 125 mg
0.16
GRISOVIN(R) ORAL TABLET 500 mg
0.63
GUAPHAN(R) ORAL SYRUP 100 mg/5ml 100 Bottle
4.95
GUPISONE(R) ORAL TABLET 20 mg
0.31
GUPISONE(R) ORAL TABLET 5 mg 20 Tab
0.31
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