Inpatient Per Day Room Rates. Charge Psychiatric Geriatric $1, Psychiatric Mood Disorder $1, Psychiatric Adult $1,070.

Transcription

1 Inpatient Per Day Room Rates Charge Psychiatric Geriatric $1, Psychiatric Mood Disorder $1, Psychiatric Adult $1, Laboratory* CPT Description Charge Ag detect nos ia mult $ Assay bld/serum cholesterol $ Assay carbamazepine total $ Assay dipropylacetic acd tot $ Assay of blood lipoprotein $ Assay of ck (cpk) $ Assay of cpk in blood $ Assay of folic acid serum $ Assay of free thyroxine $ Assay of ggt $ Assay of iron $ Assay of iron $ Assay of lipase $ Assay of lithium $ Assay of natriuretic peptide $ Assay of total thyroxine $ Assay of troponin quant $ Assay thyroid stim hormone $ Assay triiodothyronine (t3) $ Bilirubin direct $ C diff amplified probe $ Chylmd trach dna amp probe $ Complete cbc w/auto diff wbc $ Comprehen metabolic panel $ Creatine mb fraction $ Drug scrn quan levetiracetam $ Feces culture aerobic bact $ Free assay (ft-3) $ Glycosylated hemoglobin test $ Hep b core antibody igm $ Hepatic function panel $ Hepatitis a igm antibody $ Hepatitis b surface ag ia $ Hepatitis c ab test $ Hepatitis c revrs trnscrpj $ Hiv-1/hiv-2 1 result antbdy $ Influenza assay w/optic $ Lipid panel $ Metabolic panel total ca $ N.gonorrhoeae dna amp prob $ Rbc sed rate automated $3.33

2 87427 Shiga-like toxin ag ia $ Stool cultr aerobic bact ea $ Treponema pallidum $ Trichomonas vaginalis amplif $ Urinalysis auto w/o scope $ Urinalysis auto w/scope $ Urine culture/colony count $ Vitamin b-12 $ Vitamin d 25 hydroxy $70.00 Pharmacy* Description Charge per unit ACAMPROSATE CALCIUM ENTERIC COATED $0.79 ACYCLOVIR 400MG TABLET $0.85 ACYCLOVIR 800MG TABLET $1.65 ADVAIR DISKUS MCG DISK W/DEV $5.74 AFLURIA MUV, L/F, OUTER 45MCG $23.46 ALENDRONATE SODIUM OUTER 70MG TABL $9.22 ALLOPURINOL 100MG TABLET $0.22 ALPRAZOLAM 0.25MG TABLET $0.43 ALPRAZOLAM 0.5MG TABLET $0.53 ALPRAZOLAM 1MG TABLET $0.71 AMANTADINE 100MG CAPSULE $0.87 AMLODIPINE BESYLATE 10MG TABLET $1.07 AMLODIPINE BESYLATE 2.5MG TABLET $0.78 AMLODIPINE BESYLATE 5MG TABLET $0.78 AMLODIPINE-BENAZEPRIL 10MG-20MG CAP $1.49 AMLODIPINE-BENAZEPRIL 5 MG-10 MG CAP $1.22 AMMONIUM LACTATE 12% LOTION $0.07 AMOX-CLAV MG TABLET $2.27 AMOXICILLIN 500MG CAPSULE $0.17 ANTI-FUNGAL 1 % POWDER $0.03 AQUAPHOR 41 % OINT. (G) $0.03 ARIPIPRAZOLE 10MG TABLET $14.45 ARIPIPRAZOLE 15MG TABLET $14.45 ARIPIPRAZOLE 20MG TABLET $20.41 ARIPIPRAZOLE 30MG TABLET $20.41 ARIPIPRAZOLE 5MG TABLET $14.45 ASPIRIN 81MG TAB CHEW $0.01 ASPIRIN EC 81MG TABLET DR $0.01 ASPIRIN ORANGE 81MG TAB CHEW $0.02 ATENOLOL 50MG TABLET $0.36 ATOMOXETINE HCL 40MG CAPSULE $6.96 ATORVASTATIN 10MG TABLET $1.82 ATORVASTATIN 20MG TABLET $2.60 ATORVASTATIN CALCIUM F/C 40MG TABLET $2.60 AZATHIOPRINE 50MG TABLET $3.07 BACITRACIN ZINC UNIT/G OINT.(GM) $0.14

3 BACLOFEN 10MG TABLET $1.02 BACLOFEN 20MG TABLET $2.11 BENAZEPRIL HCL F/C 40MG TABLET $0.47 BENGAY GREASELESS 15%-10% CREAM (G) $0.07 BENZTROPINE MESYLATE 0.5MG TABLET $0.17 BENZTROPINE MESYLATE 1MG TABLET $0.18 BENZTROPINE MESYLATE 2MG TABLET $0.23 BENZTROPINE MESYLATE 2MG/2ML AMPUL $26.25 BIKTARVY TABLET $ BIOTENE DRY MOUTH A/F MOUTHWASH $0.01 BLISOVI FE OUTER (21) TABLET $0.30 BUPROPION HCL 75MG TABLET $0.36 BUPROPION HCL SR 150MG TAB ER 12H $0.87 BUPROPION HCL SR F/C 100MG TAB ER 12H $0.87 BUPROPION HCL SR F/C 200MG TAB ER 12H $1.62 BUPROPION XL 150MG TAB ER 24H $2.15 BUPROPION XL 300MG TAB ER 24H $2.59 BUSPIRONE HCL 10MG TABLET $0.61 BUSPIRONE HCL 15MG TABLET $0.91 BUSPIRONE HCL 30MG TABLET $1.64 BUSPIRONE HCL 5MG TABLET $0.35 BUTALB-ACETAMIN-CAFF TABLET $0.72 BUTALBITAL-ACETAMINOPHEN 50MG-300M $6.55 BUTALBITAL-ACETAMINOPHEN-CAFFE $1.32 BYSTOLIC 20MG TABLET $4.74 CALCIUM CARBONATE U-D,NA/F 200MG TAB $0.03 CALCIUM W/ VIT D 600MG-400 TABLET $0.02 CARBAMAZEPINE 100MG TAB CHEW $0.30 CARBAMAZEPINE 200MG TABLET $0.72 CARVEDILOL F/C 12.5MG TABLET $0.88 CARVEDILOL F/C 25MG TABLET $0.88 CARVEDILOL F/C 6.25MG TABLET $0.88 CEFDINIR 300MG CAPSULE $2.30 CEFTRIAXONE 1GM VIAL $20.70 CEFTRIAXONE SUV 1GM VIAL $21.18 CELECOXIB 200MG CAPSULE $3.41 CEPACOL SORE THROAT MAX NUMB,HONE $0.17 CEPHALEXIN 500MG CAPSULE $0.55 CERTAVITE SR-ANTIOXIDANT TA $0.06 CERTAVITE-ANTIOXIDANT 18MG-0.4MG TAB $0.03 CETIRIZINE HCL 10MG TABLET $1.13 CHLORDIAZEPOXIDE HCL 10MG CAPSULE $0.26 CHLORDIAZEPOXIDE HCL 25MG CAPSULE $0.28 CHLORPROMAZINE HCL 100MG TABLET $5.63 CHLORPROMAZINE HCL COATED 50MG TAB $3.94 CHLORPROMAZINE INJ 25MG/1ML AMPUL $21.05 CHLORTHALIDONE 25MG TABLET $0.54

4 CIPRODEX % DROPS $31.66 CITALOPRAM HBR F/C 10MG TABLET $1.08 CITALOPRAM HBR F/C 20MG TABLET $1.12 CITALOPRAM HBR F/C 40MG TABLET $1.17 CLONAZEPAM 0.5MG TABLET $0.49 CLONAZEPAM 1MG TABLET $0.56 CLONIDINE HCL 0.1MG TABLET $0.11 CLONIDINE HCL 0.2MG TABLET $0.20 CLONIDINE HCL 0.3MG TABLET $0.28 CLONIDINE OUTER 0.1MG24H PATCH TDWK $14.92 CLOPIDOGREL F/C 75MG TABLET $3.13 CLOTRIMAZOLE 1% CREAM $0.52 CLOZAPINE 100MG TABLET $1.50 CLOZAPINE 25MG TABLET $0.58 CLOZAPINE 50MG TABLET $0.74 CYCLOBENZAPRINE HCL F/C 10MG TABLET $0.49 DEEP SEA 0.65% SPRAY $0.02 DESITIN MAXIMUM STRENGTH 40% PASTE $0.06 DESVENLAFAXINE ER 50MG TAB ER 24H $4.06 DESVENLAFAXINE SUCCINATE ER 50MG TA $5.16 DIAZEPAM 10MG TABLET $0.21 DIAZEPAM 5MG TABLET $0.10 DICLOFENAC SODIUM 50MG TABLET DR $0.45 DICYCLOMINE HCL 20MG TABLET $0.16 DILTIAZEM 24HR ER 240MG CAP ER 24H $0.72 DILTIAZEM HCL 30MG TABLET $0.45 DIPHENHYDRAMINE HCL 25MG CAPSULE $0.01 DIPHENHYDRAMINE HCL 50MG CAPSULE $0.01 DIPHENHYDRAMINE HCL 50MG/1ML VIAL $0.58 DIVALPROEX SOD ER 250MG TAB.SR 24H $1.11 DIVALPROEX SODIUM 125MG CAP SPRINK $0.50 DIVALPROEX SODIUM 250MG TABLET DR $0.79 DIVALPROEX SODIUM 500MG TABLET DR $1.46 DIVALPROEX SODIUM ER 500MG TAB.SR 24H $1.83 DOCUSATE SODIUM SOFTGEL 100MG CAPS $0.02 DONEPEZIL HCL F/C 10MG TABLET $3.89 DONEPEZIL HCL F/C 5MG TABLET $3.89 DOXAZOSIN MESYLATE 1MG TABLET $0.61 DOXEPIN 100MG CAPSULE $0.89 DOXEPIN HCL 50MG CAPSULE $0.53 DOXYCYCLINE HYCLATE 100MG CAPSULE $2.49 DOXYCYCLINE IR-DR 40MG CAP IR DR $15.87 DULOXETINE HCL 30MG CAPSULE DR $3.14 DULOXETINE HCL 60MG CAPSULE DR $3.14 EPLERENONE F/C 50MG TABLET $1.87 ESCITALOPRAM OXALATE F/C 10MG TABLET $2.12 ESCITALOPRAM OXALATE F/C 20MG TABLET $2.21

5 ESCITALOPRAM OXALATE F/C 5MG TABLET $2.03 ESOMEPRAZOLE MAGNESIUM 20MG CAPSU $4.06 ESOMEPRAZOLE MAGNESIUM 40MG CAPSU $6.32 FAMOTIDINE 40MG TABLET $2.11 FAMOTIDINE F/C 20MG TABLET $1.09 FELODIPINE ER F/C 10MG TAB ER 24H $1.67 FEMYNOR TABLET $0.73 FENOFIBRATE 145MG TABLET $2.58 FENOFIBRATE F/C 160MG TABLET $1.07 FERROUS SULFATE 325MG TABLET $0.02 FISH OIL 1000MG CAPSULE $0.03 FLORANEX CELL TABLET $0.28 FLOVENT HFA 120 INH,DOSE COUNTER 220 $34.21 FLUCONAZOLE 100MG TABLET $3.96 FLUCONAZOLE 150MG TABLET $6.27 FLUCONAZOLE 200MG TABLET $6.48 FLUOXETINE HCL 10MG CAPSULE $1.17 FLUOXETINE HCL 20MG CAPSULE $1.20 FLUOXETINE HCL 20MG TABLET $7.31 FLUOXETINE HCL 40MG CAPSULE $2.29 FLUPHENAZINE HCL 10MG TABLET $0.75 FLUPHENAZINE HCL 2.5MG/1ML VIAL $15.37 FLUPHENAZINE HCL F/C 5MG TABLET $4.14 FLUTICASONE PROP 50MCG SPRAY SUSP $2.12 FOLIC ACID 1MG TABLET $0.04 FUROSEMIDE 20MG TABLET $0.19 FUROSEMIDE 40MG TABLET $0.22 GABAPENTIN 100MG CAPSULE $0.24 GABAPENTIN 300MG CAPSULE $0.60 GABAPENTIN 400MG CAPSULE $0.72 GABAPENTIN 600MG TABLET $1.14 GABAPENTIN F/C 800MG TABLET $1.37 GEMFIBROZIL 600MG TABLET $1.04 GEODON SDV, INNER 20MG/1ML VIAL $53.97 GLIPIZIDE 5MG TABLET $0.14 GLIPIZIDE ER 5MG TABLET $0.18 GLUCAGON EMERGENCY 1MG KIT $ GLYBURIDE 1.25MG TABLET $0.12 GLYBURIDE 2.5MG TABLET $0.21 HALOPERIDOL 10MG TABLET $0.85 HALOPERIDOL 2MG TABLET $0.28 HALOPERIDOL 5MG TABLET $0.46 HALOPERIDOL DECANOATE 100MG/1ML VIAL $27.80 HALOPERIDOL LACTATE 25'S,SDV 5MG/1ML $3.24 HUMULIN N 100UNIT/1ML UNIT $16.15 HYDRALAZINE HCL F/C 25MG TABLET $0.23 HYDROCHLOROTHIAZIDE 12.5MG CAPSULE $0.19

6 HYDROCHLOROTHIAZIDE 25MG TABLET $0.04 HYDROCHLOROTHIAZIDE 50MG TABLET $0.06 HYDROCODONE-ACET 10MG-325MG TABLET $0.44 HYDROCODONE-ACET 5MG-325MG TABLET $0.45 HYDROCODONE-ACET MG TABLET $0.34 HYDROCORTISONE MAXIMUM STRENGTH 1 $0.06 HYDROXYZINE HCL 50MG TABLET $0.50 HYDROXYZINE HCL F/C 25MG TABLET $0.41 HYDROXYZINE PAMOATE 100MG CAPSULE $0.83 HYDROXYZINE PAMOATE 25MG CAPSULE $0.26 HYDROXYZINE PAMOATE 50MG CAPSULE $0.27 HYOSCYAMINE SUBLINGUAL 0.125MG TAB S $0.39 IBUPROFEN 600MG TABLET $0.11 IPRAT-ALBUT 0.5-3MG/3 AMPUL-NEB $0.33 IRBESARTAN 150MG TABLET $1.38 JANUVIA F/C 100MG TABLET $15.56 KETOROLAC TROMETHAMINE 30MG/1ML VIAL $3.11 LABETALOL HCL F/C 100MG TABLET $0.30 LACTULOSE 10GM/15ML SOLUTION $0.03 LACTULOSE U-D, OUTER 20GM/30ML SOLUT $0.04 LAMOTRIGINE 100MG TABLET $2.34 LAMOTRIGINE 150MG TABLET $2.56 LAMOTRIGINE 200MG TABLET $2.79 LAMOTRIGINE 25MG TABLET $2.05 LANTUS 100UNITS/1ML UNIT $29.28 LATANOPROST % DROPS $4.39 LATUDA 120MG TABLET $66.13 LATUDA 20MG TABLET $44.30 LATUDA 40MG TABLET $44.30 LATUDA 60MG TABLET $44.30 LEVALBUTEROL TARTRATE HFA 45MCG HF $3.44 LEVOCETIRIZINE 5MG TABLET $1.38 LEVOTHYROXINE SODIUM 100MCG TABLET $0.25 LEVOTHYROXINE SODIUM 112MCG TABLET $0.29 LEVOTHYROXINE SODIUM 125MCG TABLET $0.30 LEVOTHYROXINE SODIUM 150MCG TABLET $0.31 LEVOTHYROXINE SODIUM 25MCG TABLET $0.20 LEVOTHYROXINE SODIUM 50MCG TABLET $0.22 LEVOTHYROXINE SODIUM 75MCG TABLET $0.25 LIDOCAINE 5% ADH. PATCH $4.63 LIDOCAINE VISCOUS 20MG/1ML SOLUTION $0.06 LINZESS 290MCG CAPSULE $14.02 LISINOPRIL 10MG TABLET $0.45 LISINOPRIL 20MG TABLET $0.48 LISINOPRIL 40MG TABLET $0.69 LISINOPRIL 5MG TABLET $0.43 LISINOPRIL-HCTZ MG TABLET $0.55

7 LITHIUM CARB ER U-D 300MG TABLET SA $0.21 LITHIUM CARBONATE 300MG CAPSULE $0.08 LITHIUM CARBONATE 450MG TABLET SA $0.24 LITHIUM CARBONATE 600MG CAPSULE $0.18 LO LOESTRIN FE 1MG-10(24) TABLET $4.99 LOPERAMIDE 2MG CAPSULE $0.47 LORATADINE NON-DROWSY 10MG TABLET $0.14 LORAZEPAM 0.5MG TABLET $0.41 LORAZEPAM 1MG TABLET $0.36 LORAZEPAM 2MG TABLET $0.79 LORAZEPAM 2MG/1ML VIAL $0.40 LOSARTAN POTASSIUM F/C 100MG TABLET $1.39 LOSARTAN POTASSIUM F/C 25MG TABLET $0.76 LOSARTAN POTASSIUM F/C 50MG TABLET $1.02 LOVASTATIN 20MG TABLET $1.07 LOVASTATIN 40MG TABLET $1.92 MAG-AL PLUS 100'S,U-D,10X10,S/F $0.04 MAGNESIUM OXIDE 400MG TABLET $0.04 MAPAP 325MG TABLET $0.01 MELATONIN 5MG TABLET $0.01 MELOXICAM 15MG TABLET $2.18 MELOXICAM 7.5MG TABLET $1.43 MEMANTINE HCL F/C 10MG TABLET $2.74 METFORMIN HCL ER 1000MG TAB ER 24 $14.13 METFORMIN HCL ER 500MG TAB ER 24H $0.35 METFORMIN HCL F/C 1000MG TABLET $0.63 METFORMIN HCL F/C 500MG TABLET $0.31 METHIMAZOLE U-D 10MG TABLET $0.35 METHOCARBAMOL 750MG TABLET $0.31 METHOCARBAMOL F/C 500MG TABLET $0.58 METHYLPHENIDATE HCL 10MG TABLET $0.47 METOPROLOL SUCC 100MG TAB ER 24H $0.71 METOPROLOL SUCC ER 25MG TAB ER 24H $0.48 METOPROLOL SUCC ER 50MG TAB ER 24H $0.47 METOPROLOL TARTRATE 100MG TABLET $0.34 METOPROLOL TARTRATE 25MG TABLET $0.11 METOPROLOL TARTRATE 50MG TABLET $0.25 METRONIDAZOLE 250MG TABLET $0.20 MILK OF MAGNESIA 100'S, U-D 400MG/5ML O $0.04 MIRTAZAPINE 15MG TAB RAPDIS $1.17 MIRTAZAPINE 15MG TABLET $1.22 MIRTAZAPINE 30MG TABLET $1.26 MIRTAZAPINE 45MG TABLET $1.28 MIRTAZAPINE F/C 7.5MG TABLET $1.18 MODAFINIL 200MG TABLET $17.97 MOMETASONE FUROATE 50MCG SPRAY/PU $7.07 MONTELUKAST SODIUM 10MG TABLET $2.55

8 MOXIFLOXACIN 0.5 % DROPS $25.10 MUCINEX 600MG TBBP 12HR $0.40 MURINE 6.5% EAR DROPS 6.5% DROPS $0.29 MYRBETRIQ F/C 50MG TAB ER 24H $12.77 NALTREXONE HCL F/C 50MG TABLET $1.92 NAPROXEN 375MG TABLET $0.48 NAPROXEN 500MG TABLET $0.52 NAPROXEN SODIUM 220MG TABLET $0.04 NATEGLINIDE 60MG TABLET $0.75 NICOTINE 2MG GUM $0.18 NICOTINE GUM COATED,CINNAMON,S/F 4M $0.27 NICOTINE PATCH 14MG24H PATCH TD24 $0.96 NICOTINE PATCH 7MG24H PATCH TD24 $2.94 NICOTINE PATCH INNER 21MG24H PATCH T $1.65 NITROFURAN MONO-MARCRO 100MG CAPS $1.72 NITROFURANTOIN MACRO 50MG CAPSULE $1.02 NYSTATIN UNIT/1GM CREAM (G) $0.39 OLANZAPINE 10MG VIAL $18.68 OLANZAPINE F/C 10MG TABLET $8.34 OLANZAPINE F/C 15MG TABLET $13.44 OLANZAPINE F/C 2.5MG TABLET $4.69 OLANZAPINE F/C 20MG TABLET $16.67 OLANZAPINE F/C 5MG TABLET $5.53 OLANZAPINE F/C 7.5MG TABLET $6.73 OLANZAPINE ODT 5MG TAB RAPDIS $6.43 OLANZAPINE UD 10MG TAB RAPDIS $9.34 OMEPRAZOLE 20MG CAPSULE DR $2.00 OMEPRAZOLE 40MG CAPSULE DR $3.33 ONDANSETRON HCL F/C 4MG TABLET $11.15 ONDANSETRON ODT UD 4MG TAB RAPDIS $10.03 OXCARBAZEPINE F/C 150MG TABLET $0.65 OXCARBAZEPINE F/C 300MG TABLET $1.19 OXYBUTYNIN CHLORIDE ER 5MG TAB ER 24 $1.48 OXYCODONE IMMEDIATE 10MG TABLET $0.28 OXYCODONE IMMEDIATE 15MG TABLET $0.85 OXYCODONE IMMEDIATE 5MG TABLET $0.31 OYSTER SHELL CALCIUM W-VIT D 250MG-12 $0.01 PALIPERIDONE ER 3MG TAB ER 24 $13.74 PALIPERIDONE ER 6MG TAB ER 24 $13.74 PANTOPRAZOLE SODIUM 40MG TABLET DR $1.84 PAROXETINE HCL F/C 10MG TABLET $1.18 PAROXETINE HCL F/C 20MG TABLET $1.20 PIOGLITAZONE HCL 45MG TABLET $5.23 POLYETHYLENE GLYCOL GM PACKET $1.11 POTASSIUM CHLORIDE 10MEQ CAPSULE SA $0.45 POTASSIUM CL ER (K-T) 20MEQ TABLET ER $0.44 POTASSIUM CL ER 20MEQ TAB ER PRT $0.28

9 PRAMIPEXOLE DIHYDROCHLORIDE 0.5MG T $1.50 PRAVASTATIN SODIUM 20MG TABLET $1.47 PRAZOSIN HCL 1MG CAPSULE $0.40 PRAZOSIN HCL 2MG CAPSULE $0.57 PREDNISONE 20MG TABLET $0.12 PREDNISONE 5MG TABLET $0.10 PREMARIN VAGINAL 0.625MG/1GM CREAM/A $12.88 PRENATAL 27MG-0.8MG TABLET $0.05 PROCTOFOAM-HC 1 %-1 % FOAM $15.48 PROCTOSOL HC 2.5% CREAM $2.68 PROMETHAZINE HCL 25MG/1ML VIAL $1.00 PROPAFENONE HCL F/C 150MG TABLET $0.74 PROPRANOLOL HCL 10MG TABLET $0.17 PROPRANOLOL HCL 20MG TABLET $0.22 QUETIAPINE FUMARATE ER 200MG TAB ER $7.89 QUETIAPINE FUMARATE ER 300MG TAB ER $10.34 QUETIAPINE FUMARATE ER 50MG TAB ER 2 $3.99 QUETIAPINE FUMARATE F/C 100MG TABLET $3.09 QUETIAPINE FUMARATE F/C 200MG TABLET $5.82 QUETIAPINE FUMARATE F/C 25MG TABLET $1.80 QUETIAPINE FUMARATE F/C 300MG TABLET $7.63 QUETIAPINE FUMARATE F/C 400MG TABLET $8.97 QUETIAPINE FUMARATE F/C 50MG TABLET $2.96 RALOXIFENE HCL F/C 60MG TABLET $3.20 RANITIDINE HCL F/C 150MG TABLET $0.70 RISPERIDONE F/C 0.25MG TABLET $1.76 RISPERIDONE F/C 0.5MG TABLET $1.92 RISPERIDONE F/C 1MG TABLET $2.05 RISPERIDONE F/C 2MG TABLET $3.42 RISPERIDONE F/C 3MG TABLET $4.02 RISPERIDONE F/C 4MG TABLET $5.40 RISPERIDONE ODT 7X4 UD 2MG TAB RAPDIS $4.03 RISPERIDONE ODT UD 3MG TAB RAPDIS $5.30 ROLAIDS REGULAR-STR, MINT MG T $0.03 ROSUVASTATIN CALCIUM 40MG TABLET $4.03 SENEXON 8.6MG TABLET $0.02 SERTRALINE HCL F/C 100MG TABLET $1.28 SERTRALINE HCL F/C 25MG TABLET $1.28 SERTRALINE HCL F/C 50MG TABLET $1.29 SIMPLY SALINE NASAL MIST ORIG 0.9 % SP $0.10 SIMVASTATIN F/C 10MG TABLET $1.27 SIMVASTATIN F/C 20MG TABLET $2.21 SPIRIVA 5 CAPS W/HANDIHALER 18MCG CA $17.11 SPIRONOLACTONE 25MG TABLET $0.21 SPIRONOLACTONE 50MG TABLET $0.37 STERILE WATER FOR INJ #5ML VIAL $0.42 SUCRALFATE 1GM TABLET $0.36

10 SULFAMETHOXAZOLE-TRIMETHOPRIM 800- $0.41 SYMBICORT 120 INHALATIONS MCG $34.85 SYMBICORT 60 INHALATIONS, INST M $30.43 T.E.D KNEE MD REG WHT CLSD TOE E $5.91 T.E.D KNEE LG LNG WHT EACH $2.91 TELFA 12'S,STERLE,OUCHLESS 3"X8" BAND $0.19 TELMISARTAN 40MG TABLET $2.51 TELMISARTAN 80MG TABLET $2.51 TEMAZEPAM 15MG CAPSULE $0.53 THERA 400MCG TABLET $0.01 THERA-M 9MG-400MCG TABLET $0.02 TIZANIDINE HCL 2MG TABLET $0.55 TIZANIDINE HCL 4MG TABLET $0.66 TOPIRAMATE F/C 100MG TABLET $2.72 TOPIRAMATE F/C 25MG TABLET $1.00 TOPIRAMATE F/C 50MG TABLET $1.99 TORSEMIDE 20MG TABLET $0.37 TRAMADOL HCL F/C 50MG TABLET $0.54 TRAZODONE HCL 100MG TABLET $0.63 TRAZODONE HCL 150MG TABLET $1.26 TRAZODONE HCL 300MG TABLET $2.45 TRAZODONE HCL 50MG TABLET $0.48 TRETINOIN 0.05 % CREAM (G) $2.53 TRIAMCINOLONE ACETONIDE 0.1 % CREAM $0.08 TRIAMCINOLONE ACETONIDE 0.5% CREAM $0.30 TRIAMTERENE-HCTZ MG TABLET $0.17 TROSPIUM CHLORIDE ER ONCE-DAILY 60M $3.03 VALPROIC ACID 250MG CAPSULE $0.38 VALPROIC ACID 250MG/5ML SYRUP $0.07 VENLAFAXINE HCL 75MG TABLET $0.98 VENLAFAXINE HCL ER 150MG CAP.SR 24H $2.29 VENLAFAXINE HCL ER 150MG TAB ER 24 $3.39 VENLAFAXINE HCL ER 37.5MG CAP.SR 24H $1.87 VENLAFAXINE HCL ER 75MG CAP.SR 24H $2.10 VENTOLIN HFA 60 ACTUATIONS 90MCG HFA $2.91 VENTOLIN HFA DOSE COUNTER,200 INH 90 $3.24 VERAPAMIL ER F/C 240MG TABLET ER $1.39 VESICARE 10MG TABLET $13.17 VIIBRYD 20MG TABLET $9.00 VITAMIN B-1 100MG TABLET $0.02 VITAMIN B-12 1,000MCG TAB SUBL $0.03 VITAMIN B MCG TABLET $0.03 VITAMIN B MCG TABLET $0.01 VITAMIN C 500MG TABLET $0.01 VITAMIN D GLUTEN/F, D/F 1000UNIT TABLET $0.01 VITAMIN D UNIT TABLET $0.01 VITAMIN D3 5000UNIT TABLET $0.01

11 VITAMIN D3 S/F,P/F 2000UNIT TABLET $0.01 VOLTAREN 1 % GEL (GRAM) $0.59 VRAYLAR 3MG CAPSULE $43.48 WARFARIN SODIUM 7.5MG TABLET $0.44 ZINC OXIDE 20% OINTMENT $0.04 ZIPRASIDONE HCL 20MG CAPSULE $4.03 ZIPRASIDONE HCL 40MG CAPSULE $4.03 ZIPRASIDONE HCL 60MG CAPSULE $4.90 ZIPRASIDONE HCL 80MG CAPSULE $4.90 ZOLPIDEM TARTRATE F/C 10MG TABLET $3.01 ZOLPIDEM TARTRATE F/C 5MG TABLET $3.01 *Amount listed represents charge as billed to the hospital by outside purchased services laboratory or pharmacy vendor.