Charge Master Code Description Price HCPCS Code Revenue Code Effective Date Department Medicare Part B After Deductible Medicaid Private Pay Blue Cross UMR United Healthcare Cigna Aetna "Champ VA Yearly Deductible" 422330 RED BLOOD CELLS $517.00 P9016 390 7/1/2018 zzLRMH_CC_Blood Bank $0.00 $0.00 $258.50 $77.55 $51.70 $77.55 $103.40 $103.40 $0.00 422385 FRESH FROZEN PLASMA $179.00 P9019 390 7/1/2018 zzLRMH_CC_Blood Bank $0.00 $0.00 $89.50 $26.85 $17.90 $26.85 $35.80 $35.80 $0.00 422334360 "TRANSFUSION, BLOOD,BLOOD COMP" $873.00 36430 391 7/1/2018 zzLRMH_CC_Blood Bank $0.00 $0.00 $436.50 $130.95 $87.30 $130.95 $174.60 $174.60 $0.00 32511 EXTERNAL PACER PAD $138.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $69.00 $20.70 $13.80 $20.70 $27.60 $27.60 $0.00 32515 GAUZE DRAIN 4X4 ST $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 325123 HUBER NEEDLE 19 X 1 $19.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 325124 HUBER NEEDLE 19 X 3/4 $19.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 325125 F/C COUDE 12 FR X 5CC $56.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $28.00 $8.40 $5.60 $8.40 $11.20 $11.20 $0.00 325126 F/C COUDE 14 FR X 5CC $56.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $28.00 $8.40 $5.60 $8.40 $11.20 $11.20 $0.00 325127 HUBER NEEDLE 22 X 1 $19.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 325128 F/C COUDE 18 FR X 5CC $56.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $28.00 $8.40 $5.60 $8.40 $11.20 $11.20 $0.00 325129 HUBER NEEDLE 20 X 1 $19.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 325140 MIDSTREAM COLLECTOR $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 325150 CATH TRAY W/O CATH $70.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $35.00 $10.50 $7.00 $10.50 $14.00 $14.00 $0.00 325160 CATH TRAY 16 $86.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $43.00 $12.90 $8.60 $12.90 $17.20 $17.20 $0.00 325170 URETHRAL TRAY $24.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.00 $3.60 $2.40 $3.60 $4.80 $4.80 $0.00 325180 IRRIGATION TRAY $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 3251100 V PAD $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 3251110 F/C 12 FR X 5CC $58.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $29.00 $8.70 $5.80 $8.70 $11.60 $11.60 $0.00 3251111 CENTRAL VENOUS KIT $343.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $171.50 $51.45 $34.30 $51.45 $68.60 $68.60 $0.00 3251116 STERILE WATER 250ML $11.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 3251117 SC IRRIGATION 250 ML $11.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 3251130 ENEMA SET $9.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.50 $1.35 $0.90 $1.35 $1.80 $1.80 $0.00 3251170 ICE PACK $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 3251220 FLATUS BAG $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 3251230 YANKAUER HANDLE $20.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 3251260 ENEMA FLEET SALINE $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 3251261 ENEMA FLEET OIL $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 3251270 TELFA 3 X 6 $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 3251280 TELFA 3 X 4 $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 3251290 TELFA 4 X 8 $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 3251300 BANDAID $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 3251310 GAUZE 4X4 ST PKG $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 3251330 KERLIX ROLL $6.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 3251351 PLAIN PACKING 1/2 IN $24.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.00 $3.60 $2.40 $3.60 $4.80 $4.80 $0.00 3251352 PLAIN PACKING 1/4 IN $24.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.00 $3.60 $2.40 $3.60 $4.80 $4.80 $0.00 3251360 IODOFORM 1 IN $27.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $13.50 $4.05 $2.70 $4.05 $5.40 $5.40 $0.00 3251361 IODOFORM 1/2 IN $27.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $13.50 $4.05 $2.70 $4.05 $5.40 $5.40 $0.00 3251362 IODOFORM 1/4 IN $27.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $13.50 $4.05 $2.70 $4.05 $5.40 $5.40 $0.00 3251431 LARYNGEAL MASK AIRWAY SIZE 1 $24.00 272 11/1/2020 zzLRMH_CC_Central Supply $0.00 $0.00 $12.00 $3.60 $2.40 $3.60 $4.80 $4.80 $0.00 3251432 LARYNGEAL MASK AIRWAY SIZE 2 $23.00 272 11/1/2020 zzLRMH_CC_Central Supply $0.00 $0.00 $11.50 $3.45 $2.30 $3.45 $4.60 $4.60 $0.00 3251433 LARYNGEAL MASK AIRWAY SIZE 3 $24.00 272 11/1/2020 zzLRMH_CC_Central Supply $0.00 $0.00 $12.00 $3.60 $2.40 $3.60 $4.80 $4.80 $0.00 3251434 LARYNGEAL MASK AIRWAY SIZE 4 $26.00 272 11/1/2020 zzLRMH_CC_Central Supply $0.00 $0.00 $13.00 $3.90 $2.60 $3.90 $5.20 $5.20 $0.00 3251435 LARYNGEAL MASK AIRWAY SIZE 5 $24.00 272 11/1/2020 zzLRMH_CC_Central Supply $0.00 $0.00 $12.00 $3.60 $2.40 $3.60 $4.80 $4.80 $0.00 3251436 LARYNGEAL MASK AIRWAY SIZE 6 $25.00 272 11/1/2020 zzLRMH_CC_Central Supply $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 3251500 ELASTOPLAST $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 3251501 IV BURETROL SET $43.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 3251510 ORAL AIRWAY ADULT LG $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 3251511 ORAL AIRWAY ADULT M $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 3251520 ENDO TUBE 2.5 $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 3251527 ENDO TUBE 7.0 $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 3251528 ENDO TUBE 7.5 $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 3251530 KNEE IMMOB 20 IN LG $152.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 3251533 KNEE IMMOB 20 IN XL $152.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 3251536 KNEE IMMOB 24 IN LG $152.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 3251537 KNEE IMMOB 24 IN M $152.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 3251560 ARM SLING LG $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 3251561 ARM SLING MED $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 3251562 ARM SLING SM $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 3251563 ARM SLING XSM $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 3251564 ARM SLING XLG $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 3251596 CERVICAL COLLAR LG $41.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $20.50 $6.15 $4.10 $6.15 $8.20 $8.20 $0.00 3251597 CERVICAL COLLAR MED $41.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $20.50 $6.15 $4.10 $6.15 $8.20 $8.20 $0.00 3251598 CERVICAL COLLAR SM $41.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $20.50 $6.15 $4.10 $6.15 $8.20 $8.20 $0.00 3251600 CERVICAL COLLAR XLG $41.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $20.50 $6.15 $4.10 $6.15 $8.20 $8.20 $0.00 3251612 WRIST & FOREARM LT L $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251613 WRIST & FOREARM RT LG $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251614 WRIST & FOREARM LT M $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251615 WRIST & FOREARM RT M $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251616 WRIST & FOREARM RT XS $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251617 WRIST & FOREARM RT XL $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251618 WRIST & FOREARM LT S $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251619 WRIST & FOREARM RT S $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251620 WRIST & FOREARM LT XL $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 3251627 TED KNEE REG LG $36.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 3251628 TED KNEE REG MED $36.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 3251629 TED KNEE REG SM $36.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 3251630 TED KNEE REG XL $36.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 3251636 TED THIGH LONG XL $54.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $27.00 $8.10 $5.40 $8.10 $10.80 $10.80 $0.00 3251637 TED THIGH REG LG $54.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $27.00 $8.10 $5.40 $8.10 $10.80 $10.80 $0.00 3251639 TED THIGH REG SM $54.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $27.00 $8.10 $5.40 $8.10 $10.80 $10.80 $0.00 3251640 TED THIGH REG XL $54.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $27.00 $8.10 $5.40 $8.10 $10.80 $10.80 $0.00 3251800 IV START KIT $25.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 3251801 IV CATH 18 GA $25.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 3251802 IV CATH 20 GA $25.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 3251803 IV CATH 22 GA $25.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 3251804 IV CATH 24 GA $25.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 3251815 IV INJECTION SITE $27.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $13.50 $4.05 $2.70 $4.05 $5.40 $5.40 $0.00 3251816 IV INJECT SITE W/TUBING $43.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 3251817 IV PRIMARY SET $43.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 3251819 IV EXTENSION TUBING $25.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 3251820 IV SECONDARY SET $28.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 3251821 IV FILTER DILANTEN $36.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 3259127 F/C COUDE 16 FR X 5CC $56.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $28.00 $8.40 $5.60 $8.40 $11.20 $11.20 $0.00 32501537 COUDE CATH 16FR X 5CC $22.24 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $11.12 $3.34 $2.22 $3.34 $4.45 $4.45 $0.00 32501882 HUBER NEEDLE 20 X 3/4 $19.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 32501883 HUBER NEEDLE 22 X 3/4 $19.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 32503079 PICC GUARD IVA DRESSING $12.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 32503080 PICC NEEDLE GUIDE KIT $30.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 32503081 PICC CATHETER KIT 5FR $689.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $344.50 $103.35 $68.90 $103.35 $137.80 $137.80 $0.00 32510126 PEDI URINE COLLECTOR $2.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 32511001 MEPILEX AG 4X4 DRESSING $48.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 32511100 NASAL PACKING 4.5 $37.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $18.50 $5.55 $3.70 $5.55 $7.40 $7.40 $0.00 32511101 NASAL PACKING 8.0 $46.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $23.00 $6.90 $4.60 $6.90 $9.20 $9.20 $0.00 32511111 F/C SIL 14FR X 5CC $58.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $29.00 $8.70 $5.80 $8.70 $11.60 $11.60 $0.00 32511113 F/C SIL 16 FR X 5CC $58.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $29.00 $8.70 $5.80 $8.70 $11.60 $11.60 $0.00 32511122 F/C SIL 26 FR X 30CC $58.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $29.00 $8.70 $5.80 $8.70 $11.60 $11.60 $0.00 32511170 EYE PADS $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 32511180 ELASTIC BANDAGE 2 IN $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511181 ELASTIC BANDAGE 4 IN $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511182 ELASTIC BANDAGE 6 IN $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511190 CHUX $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511225 SPLINT CLAVICAL LG $68.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 32511226 SPLINT CLAVICAL MED $68.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 32511227 SPLINT CLAVICAL SM $68.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 32511230 SPLINT CLAVICLE XXS $68.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 32511236 SHOULDER IMMOB LG $74.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $37.00 $11.10 $7.40 $11.10 $14.80 $14.80 $0.00 32511237 SHOULDER IMMOB MED $74.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $37.00 $11.10 $7.40 $11.10 $14.80 $14.80 $0.00 32511240 SHOULDER IMMOB XLG $74.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $37.00 $11.10 $7.40 $11.10 $14.80 $14.80 $0.00 32511280 SUCTION CATH 10FR $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511290 SUCTION CATH 14FR $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511291 SUCTION CATH 18FR $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511300 SALEM SUMP 14 FR $9.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.50 $1.35 $0.90 $1.35 $1.80 $1.80 $0.00 32511301 SALEM SUMP 16FR $9.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.50 $1.35 $0.90 $1.35 $1.80 $1.80 $0.00 32511302 SALEM SUMP 18FR $9.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.50 $1.35 $0.90 $1.35 $1.80 $1.80 $0.00 32511310 SUCTION TUBING 6 FT $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511311 SUCTION TUBING 12 FT $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511330 SUTURE REMOVAL TRAY $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511337 IV ONE LINK EXTENSION SET $35.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 32511340 EAR TRAY $8.00 270 10/1/2022 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511350 HEEL/ELBOW PROTECTOR $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 32511360 RESTRAINT LIMB $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 32511440 SPUTUM CUP $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32511470 TROCAR CATH 32 FR $50.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 32511578 SPLINT BASEBALL LG $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 32511579 SPLINT BASEBALL MED $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 32511580 SPLINT BASEBALL SM $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 32511590 SPLINT GUTTER SM $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 32511591 SPLINT COCK UP M $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 32511593 SPLINT COLLES L LG $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 32511594 SPLINT COLLES L M $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 32511598 SPLINT COLLES R LG $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 32511599 SPLINT COLLES R MED $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 32511600 SPLINT COLLES R SM $61.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 32511630 DRESSING TRAY SMALL $12.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 32511640 SUTURE OR STAPLE TRAY SMALL 1-4 $100.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 32511660 SUTURE OR STAPLE TRAY MEDIUM 5-8 $108.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $54.00 $16.20 $10.80 $16.20 $21.60 $21.60 $0.00 32511670 SUTURE OR STAPLE TRAY LARGE 9AND OVER $126.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $63.00 $18.90 $12.60 $18.90 $25.20 $25.20 $0.00 32511680 LG WOUND DRESSING TRAY $100.00 272 6/1/2022 zzLRMH_CC_Central Supply $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 32511690 PREP TRAY $20.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 32511700 PELVIC EXAM TRAY $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 32512057 EMERGENCY CRICOTHYROTOMY KIT $71.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $35.50 $10.65 $7.10 $10.65 $14.20 $14.20 $0.00 32512345 IV FLUID INFUSION WARMER $233.00 272 12/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $116.50 $34.95 $23.30 $34.95 $46.60 $46.60 $0.00 32512560 EYE TRAY $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 32512600 GASTRIC LAVAGE $43.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 32512640 INCISION/DRAIN TRAY $63.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 32512672 RAPID RHINO 7.5 CM $68.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 32512880 VASELINE DRESSING 3 X 9 $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32512950 DIAPERS ADULT LG $35.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 32512959 MEPILEX BORDER 4X12 $48.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 32512960 TRACH TRAY $35.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 32513000 KNEE SUPPORT XL $63.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 32513001 KNEE SUPPORT LG $63.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 32513002 KNEE SUPPORT MED $63.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 32513003 KNEE SUPPORT SM $63.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 32513080 ARTHROCENTESIS TRAY $64.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 32513120 BURN DRESSING TRAY MED $63.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 32513130 BURN DRESSING TRAY SMALL $29.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $14.50 $4.35 $2.90 $4.35 $5.80 $5.80 $0.00 32513160 ENT TRAY $27.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $13.50 $4.05 $2.70 $4.05 $5.40 $5.40 $0.00 32513194 POST OP SHOE FEMALE M $64.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 32513195 POST OP SHOE FEMALE L $64.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 32513196 POST OP SHOE FEMALE S $64.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 32513197 POST OP SHOE MALE L $64.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 32513198 POST OP SHOE MALE M $64.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 32513199 POST OP SHOE MALE S $64.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 32513200 POST OP SHOE MALE XL $64.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 32513206 TROCAR CATH 28FR $50.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 32513207 TROCAR CATH 20FR $50.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 32513220 BETADINE SOAK $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32513258 EZ-IO STABILIZER $38.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $19.00 $5.70 $3.80 $5.70 $7.60 $7.60 $0.00 32513291 TRACH TUBE SZ 6 $40.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $20.00 $6.00 $4.00 $6.00 $8.00 $8.00 $0.00 32513337 PICC STATLOCK DEVICE $11.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 32513396 MEPILEX DRESSING 4X8 $45.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $22.50 $6.75 $4.50 $6.75 $9.00 $9.00 $0.00 32513471 AQUACEL FOAM 4X4 $45.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $22.50 $6.75 $4.50 $6.75 $9.00 $9.00 $0.00 32513472 IODOFLEX 1.6X2.4 $45.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $22.50 $6.75 $4.50 $6.75 $9.00 $9.00 $0.00 32513534 STERILE SALINE SOLUTION $11.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 32513680 HIBICLENS SOAK $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32513685 HIBICLENS $23.00 A4246 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $11.50 $3.45 $2.30 $3.45 $4.60 $4.60 $0.00 32513700 NUGAUZE PLAIN $11.00 A6407 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 32513830 PLEUR EVAC $300.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $150.00 $45.00 $30.00 $45.00 $60.00 $60.00 $0.00 32514240 F/C 8 FR PEDI $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 32514638 XEROFORM PETROLATUM $2.00 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 32514980 SPECIMEN CONTAINER $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 32514990 SPECIMEN TRAP $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 32515001 AIR CAST LT LG $89.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 32515002 AIR CAST LT MED $89.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 32515005 AIR CAST RT MED $89.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 32515500 IV VENTED TUBING $43.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 32515501 IV NITRO SET $84.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $42.00 $12.60 $8.40 $12.60 $16.80 $16.80 $0.00 32515897 SCD EXPRESS KNEE $44.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $22.00 $6.60 $4.40 $6.60 $8.80 $8.80 $0.00 32515898 SCD EXPRESS FOOT $88.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.00 $13.20 $8.80 $13.20 $17.60 $17.60 $0.00 32516001 ELASTIC ANKLE SUPP LG $89.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 32516002 ELASTIC ANKLE SUPP M $89.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 32516003 ELASTIC ANKLE SUPP SM $89.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 32516550 FEMALE CATH KIT $20.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 32516557 ALARM PAD BED $58.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $29.00 $8.70 $5.80 $8.70 $11.60 $11.60 $0.00 32516558 ALARM PAD CHAIR $58.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $29.00 $8.70 $5.80 $8.70 $11.60 $11.60 $0.00 32516650 ELASTIC ANKLE SUPP XXL $89.00 L4350 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 32516651 AIR CAST UNIVERSAL SM $89.00 L4350 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 32516652 MORGAN LENS SET $59.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $29.50 $8.85 $5.90 $8.85 $11.80 $11.80 $0.00 32517101 MORGAN LENS MEDI FLOW $68.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 32517197 ANKLE LEATHER LG $81.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $40.50 $12.15 $8.10 $12.15 $16.20 $16.20 $0.00 32517198 ANKLE LEATHER MED $81.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $40.50 $12.15 $8.10 $12.15 $16.20 $16.20 $0.00 32518071 IV VIAL ADAPTER $50.00 272 12/1/2019 zzLRMH_CC_Central Supply $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 32518531 KNEE IMMOB 20IN MED $152.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 32518532 KNEE IMMOB 20IN SM $152.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 32519637 ENDOTRACH HOLDER ADULT $11.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 32548750 Y TYPE BLOOD SET $60.00 270 12/1/2023 zzLRMH_CC_Central Supply $0.00 $0.00 $30.00 $9.00 $6.00 $9.00 $12.00 $12.00 $0.00 32611601 FINGER COT 1 1/2 SM $18.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.00 $2.70 $1.80 $2.70 $3.60 $3.60 $0.00 32611602 FINGER COT 2IN MED $18.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.00 $2.70 $1.80 $2.70 $3.60 $3.60 $0.00 32611603 FINGER COT 3 1/4 LG $18.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.00 $2.70 $1.80 $2.70 $3.60 $3.60 $0.00 32611604 FINGER COT 3-3/4 XL $18.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $9.00 $2.70 $1.80 $2.70 $3.60 $3.60 $0.00 40711682 SALINE FLUSH SYRINGE 10ML $6.00 A4216 272 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 51980012 STIFNECK COLLAR ADULT $37.00 L0150 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $18.50 $5.55 $3.70 $5.55 $7.40 $7.40 $0.00 51980020 STIFNECK COLLAR PEDI $37.00 L0150 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $18.50 $5.55 $3.70 $5.55 $7.40 $7.40 $0.00 325105740 GLIDESCOPE 1 $52.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $26.00 $7.80 $5.20 $7.80 $10.40 $10.40 $0.00 325105742 GLIDESCOPE 3 $52.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $26.00 $7.80 $5.20 $7.80 $10.40 $10.40 $0.00 325105743 GLIDESCOPE 4 $38.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $19.00 $5.70 $3.80 $5.70 $7.60 $7.60 $0.00 325107200 ATTENDS BRIEFS M $15.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 325107300 ATTENDS BRIEFS LG $15.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 325110002 FIBERCAL PLUS 4X4 DRESSING $43.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 325110252 AIR FLOW MATTRESS $83.00 E0191 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $41.50 $12.45 $8.30 $12.45 $16.60 $16.60 $0.00 325111011 SPLINT CRUSHED FINGER LG $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325111013 SPLINT FINGER VELCRO L $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 325111014 SPLINT FINGER VELCRO M $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 325111015 SPLINT FINGER VELCRO S $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 325111017 SPLINT FOLD OVER MED $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325111018 SPLINT GUTTER 6 IN LG $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325111019 SPLINT GUTTER 7IN $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325111020 SPLINT GUTTER M $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325111041 DERMABOND $78.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $39.00 $11.70 $7.80 $11.70 $15.60 $15.60 $0.00 325111187 BETADINE SWABS $2.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 325111189 DRESSING CHANGE TRAY $26.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $13.00 $3.90 $2.60 $3.90 $5.20 $5.20 $0.00 325111704 LACERATION TRAY $34.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $17.00 $5.10 $3.40 $5.10 $6.80 $6.80 $0.00 325111941 STAPLE REMOVER $20.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 325112001 MOISTURE BARRIER $26.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $13.00 $3.90 $2.60 $3.90 $5.20 $5.20 $0.00 325112009 CARRA FOAM $30.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 325114604 FLANGE FLOATING /W TAPE 2 3/4 $7.00 272 7/1/2019 zzLRMH_CC_Central Supply $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 325115901 STAPLE- PER EACH $3.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 325118404 POUCH IMAGE UROSTOMY $6.00 272 7/1/2019 zzLRMH_CC_Central Supply $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 325120467 SILVER NITRATE STICKS $1.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 325131610 EAR IRRIGATION WITH SOLUTION $13.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $6.50 $1.95 $1.30 $1.95 $2.60 $2.60 $0.00 325141090 PLASTIC COLLAR MED $35.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 325156550 THORACOSTOMY TRAY $72.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $36.00 $10.80 $7.20 $10.80 $14.40 $14.40 $0.00 325159010 GAUZE SPONGE 4X4 ST $6.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 325159030 LEG BAG LG $12.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 325159031 LEG BAG MED $12.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 325159064 COMBIDERM 4X4 $6.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 325160871 AQUACEL AG 4X5 $50.00 A6197 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 325161960 AQUACEL AG 2X2 $45.00 A6196 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $22.50 $6.75 $4.50 $6.75 $9.00 $9.00 $0.00 325163240 TEGADERM 2 X 2 $12.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 325163242 THERAPY PAD $26.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $13.00 $3.90 $2.60 $3.90 $5.20 $5.20 $0.00 325163243 TEGADERM 4 X 4 $12.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 325167284 TEGADERM 6X8 $8.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 325174326 HYDROFERA BLUE 6X6 $39.00 A6210 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $19.50 $5.85 $3.90 $5.85 $7.80 $7.80 $0.00 325174327 HYDROFERA BLUE 4X4 $21.00 A6209 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325181016 SPLINT FOLD OVER LG $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325182600 EASY LAVAGE $173.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $86.50 $25.95 $17.30 $25.95 $34.60 $34.60 $0.00 325191014 SPLINT CRUSHED FINGER S/M $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325191015 SPLINT CRUSHED FINGER S $21.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 325195035 SIDEKICK WALKER LG $138.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $69.00 $20.70 $13.80 $20.70 $27.60 $27.60 $0.00 325195036 SIDEKICK WALKER M $138.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $69.00 $20.70 $13.80 $20.70 $27.60 $27.60 $0.00 325195037 SIDEKICK WALKER SM $138.00 274 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $69.00 $20.70 $13.80 $20.70 $27.60 $27.60 $0.00 407290012 AD EZ-IO NEEDLE 25MM $273.00 A4300 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $136.50 $40.95 $27.30 $40.95 $54.60 $54.60 $0.00 407290181 PD EZ-IO NEEDLE 15MM $273.00 A4300 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $136.50 $40.95 $27.30 $40.95 $54.60 $54.60 $0.00 407290791 LD NEEDLE FOR IO PLACE 45MM $317.00 A4300 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $158.50 $47.55 $31.70 $47.55 $63.40 $63.40 $0.00 461261962 CALCIUM ALGINATE 2 X 2 $39.00 A6196 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $19.50 $5.85 $3.90 $5.85 $7.80 $7.80 $0.00 461261963 CALCIUM ALGINATE 4 X 4 $39.00 A6196 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $19.50 $5.85 $3.90 $5.85 $7.80 $7.80 $0.00 461261971 ACTICOAT 3 4 X 4 $86.00 A6197 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $43.00 $12.90 $8.60 $12.90 $17.20 $17.20 $0.00 461261974 SILVERCEL 4 1/4 X4 1/4 $86.00 A6197 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $43.00 $12.90 $8.60 $12.90 $17.20 $17.20 $0.00 461262092 HYDROFERA BLUE 4 X 4 $39.00 A6209 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $19.50 $5.85 $3.90 $5.85 $7.80 $7.80 $0.00 461262121 MEPILEX BORDER 4 X 4 $51.00 A6212 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $25.50 $7.65 $5.10 $7.65 $10.20 $10.20 $0.00 461262141 MEPILEX AG 4X4 $121.00 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $60.50 $18.15 $12.10 $18.15 $24.20 $24.20 $0.00 461262481 HYDROGEL 4 OZ TUBE $85.00 A6248 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $42.50 $12.75 $8.50 $12.75 $17.00 $17.00 $0.00 461262483 SILV-A-GEL 3 OZ $85.00 A6248 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $42.50 $12.75 $8.50 $12.75 $17.00 $17.00 $0.00 461262521 ABD PAD 5 X 9 $17.00 A6252 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $8.50 $2.55 $1.70 $2.55 $3.40 $3.40 $0.00 461262531 ABD PAD 8 X 10 $33.00 A6253 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $16.50 $4.95 $3.30 $4.95 $6.60 $6.60 $0.00 461262611 IODEFLEX 5GM PER GM $33.00 A6261 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $16.50 $4.95 $3.30 $4.95 $6.60 $6.60 $0.00 461262612 IODOSORB GEL 40CM/.250Z PER GM $233.00 A6261 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $116.50 $34.95 $23.30 $34.95 $46.60 $46.60 $0.00 461264071 NUGAUZE 1/2 IN PLAIN $10.00 A6407 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 461264491 GAUZE CONFORM 3 IN $9.00 A6449 270 7/1/2018 zzLRMH_CC_Central Supply $0.00 $0.00 $4.50 $1.35 $0.90 $1.35 $1.80 $1.80 $0.00 3.25325E+11 TENNIS ELBOW XLG $6.00 270 1/10/2017 zzLRMH_CC_Central Supply $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 404220 HEAD WITHOUT "$1,376.00" 70450 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $688.00 $206.40 $137.60 $206.40 $275.20 $275.20 $0.00 404230 HEAD WITH "$1,450.00" 70460 351 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 404240 HEAD WITH AND WITHOUT "$1,590.00" 70470 351 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $795.00 $238.50 $159.00 $238.50 $318.00 $318.00 $0.00 404250 CT ABDOMEN W/O "$1,304.00" 74150 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $652.00 $195.60 $130.40 $195.60 $260.80 $260.80 $0.00 404260 CT ABDOMEN WITH "$1,450.00" 74160 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 404270 CT ABDOMEN WITH AND WITHOUT "$1,560.00" 74170 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $780.00 $234.00 $156.00 $234.00 $312.00 $312.00 $0.00 4042110 THORAX WITHOUT "$1,276.00" 71250 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $638.00 $191.40 $127.60 $191.40 $255.20 $255.20 $0.00 4042120 THORAX WITH "$1,553.00" 71260 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $776.50 $232.95 $155.30 $232.95 $310.60 $310.60 $0.00 4042130 THORAX WITH AND WITHOUT "$1,578.00" 71270 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $789.00 $236.70 $157.80 $236.70 $315.60 $315.60 $0.00 4042230 CERVICAL SPINE WITHOUT "$1,355.00" 72125 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $677.50 $203.25 $135.50 $203.25 $271.00 $271.00 $0.00 4042240 CERVICAL SPINE WITH "$1,330.00" 72126 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $665.00 $199.50 $133.00 $199.50 $266.00 $266.00 $0.00 4042260 LUMBAR SPINE WITHOUT "$1,376.00" 72131 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $688.00 $206.40 $137.60 $206.40 $275.20 $275.20 $0.00 4042270 LUMBAR SPINE WITH "$1,450.00" 72132 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 4042280 LUMBAR SPINE WITH AND WITHOUT "$1,531.00" 72133 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $765.50 $229.65 $153.10 $229.65 $306.20 $306.20 $0.00 4042290 THORACIC SPINE WITHOUT "$1,276.00" 72128 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $638.00 $191.40 $127.60 $191.40 $255.20 $255.20 $0.00 4042320 CT SOFT TISSUE NECK WITHOUT "$1,376.00" 70490 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $688.00 $206.40 $137.60 $206.40 $275.20 $275.20 $0.00 4042330 CT SOFT TISSUE NECK WITH "$1,450.00" 70491 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 4042340 CT SOFT TISSUE NECK WITH & W/O "$1,531.00" 70492 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $765.50 $229.65 $153.10 $229.65 $306.20 $306.20 $0.00 4042350 CT MAXILLOFACIAL W/O "$1,376.00" 70486 351 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $688.00 $206.40 $137.60 $206.40 $275.20 $275.20 $0.00 4042360 CT MAXILLOFACIAL WITH CONTRAST "$1,450.00" 70487 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 4042370 CT MAXILLOFACIAL WITH AND WITHOUT CONTRAST "$1,531.00" 70492 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $765.50 $229.65 $153.10 $229.65 $306.20 $306.20 $0.00 4042440 "ORBITS,POST.FOSSA,SELLA W/O" "$1,376.00" 70480 351 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $688.00 $206.40 $137.60 $206.40 $275.20 $275.20 $0.00 4042450 "ORBITS,POST.FOSSA,SELLA WITH" "$1,450.00" 70481 351 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 4042460 "ORBITS,POST.FOSSA,SELLA W&W/O" "$1,531.00" 70482 351 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $765.50 $229.65 $153.10 $229.65 $306.20 $306.20 $0.00 4042500 PELVIS WITHOUT "$1,376.00" 72192 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $688.00 $206.40 $137.60 $206.40 $275.20 $275.20 $0.00 4042510 PELVIS WITH "$1,469.00" 72193 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $734.50 $220.35 $146.90 $220.35 $293.80 $293.80 $0.00 4042520 PELVIS WITH AND WITHOUT "$1,617.00" 72194 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $808.50 $242.55 $161.70 $242.55 $323.40 $323.40 $0.00 4042530 LOWER EXTREMITIES WITHOUT "$1,450.00" 73700 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 4042540 LOWER EXTREMITIES WITH AND WIT "$1,515.00" 73702 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $757.50 $227.25 $151.50 $227.25 $303.00 $303.00 $0.00 4042550 UPPER EXTREMITIES WITHOUT "$1,192.00" 73200 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $596.00 $178.80 $119.20 $178.80 $238.40 $238.40 $0.00 4042560 UPPER EXTREMITIES WITH AND WIT "$1,376.00" 73202 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $688.00 $206.40 $137.60 $206.40 $275.20 $275.20 $0.00 4042580 "RECONSTRUCTION,CORONAL,OBLIQUE" $331.00 76377 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $165.50 $49.65 $33.10 $49.65 $66.20 $66.20 $0.00 404270496 CTA HEAD "$1,450.00" 70496 351 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 404270498 CTA NECK "$1,450.00" 70498 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 404271275 CTA CHEST "$1,553.00" 71275 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $776.50 $232.95 $155.30 $232.95 $310.60 $310.60 $0.00 404274175 CTA ABDOMEN "$1,450.00" 74175 350 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $725.00 $217.50 $145.00 $217.50 $290.00 $290.00 $0.00 404274176 CT ABD&PELVIS WITHOUT CONTRAST "$2,112.00" 74176 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 "$1,056.00" $316.80 $211.20 $316.80 $422.40 $422.40 $0.00 404274177 CT ABD/PELVIS WITH CONTRAST "$2,112.00" 74177 352 10/28/2020 zzLRMH_CC_CT Scan $0.00 $0.00 "$1,056.00" $316.80 $211.20 $316.80 $422.40 $422.40 $0.00 404274178 CT ABD&PEL WITH/WITHOUT CONTR "$2,332.00" 74178 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 "$1,166.00" $349.80 $233.20 $349.80 $466.40 $466.40 $0.00 404276070 BMD SPINE / HIP $417.00 77078 352 7/1/2018 zzLRMH_CC_CT Scan $0.00 $0.00 $208.50 $62.55 $41.70 $62.55 $83.40 $83.40 $0.00 4042560W CT UPPER EXTREMITY W/ CONTRAST "$1,300.00" 73201 350 8/1/2023 zzLRMH_CC_CT Scan $0.00 $0.00 $650.00 $195.00 $130.00 $195.00 $260.00 $260.00 $0.00 404093307 "ECHO, TRANSTHORACIC, COMPLETE" "$1,198.00" 93306 480 7/1/2018 zzLRMH_CC_Echo $0.00 $0.00 $599.00 $179.70 $119.80 $179.70 $239.60 $239.60 $0.00 301410 DAY SURGERY BED $173.00 760 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $86.50 $25.95 $17.30 $25.95 $34.60 $34.60 $0.00 323111 ER LEVEL I $150.00 99281 450 9/21/2023 zzLRMH_CC_Emergency $0.00 $0.00 $75.00 $22.50 $15.00 $22.50 $30.00 $30.00 $0.00 323113 ER LEVEL II $134.00 99282 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $67.00 $20.10 $13.40 $20.10 $26.80 $26.80 $0.00 323114 ER LEVEL III $252.00 99283 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $126.00 $37.80 $25.20 $37.80 $50.40 $50.40 $0.00 323117 ER LEVEL IV $336.00 99284 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $168.00 $50.40 $33.60 $50.40 $67.20 $67.20 $0.00 323118 ER LEVEL V $503.00 99285 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $251.50 $75.45 $50.30 $75.45 $100.60 $100.60 $0.00 323120 CRITICAL CARE "$1,630.00" 99291 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $815.00 $244.50 $163.00 $244.50 $326.00 $326.00 $0.00 323170 BLADDER IRRIGATION SIMPLE $73.00 51700 450 4/1/2021 zzLRMH_CC_Emergency $0.00 $0.00 $36.50 $10.95 $7.30 $10.95 $14.60 $14.60 $0.00 3231100 TRIAGE MEDICAL SCREENING ONLY $53.00 99281 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 3232230 EKG INTERPRETATION $41.00 93010 981 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $20.50 $6.15 $4.10 $6.15 $8.20 $8.20 $0.00 5010425 TELEMED 30 MIN CONSULT $223.00 G0425 780 8/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $111.50 $33.45 $22.30 $33.45 $44.60 $44.60 $0.00 5010426 TELEMED CONSULT 50 MIN $303.00 G0426 780 8/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $151.50 $45.45 $30.30 $45.45 $60.60 $60.60 $0.00 5010427 TELEMED CONSULT 70 MIN $450.00 G0427 780 8/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $225.00 $67.50 $45.00 $67.50 $90.00 $90.00 $0.00 5010508 TELEMED CRIT CARE FIRST 60 MIN $466.00 G0508 780 8/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $233.00 $69.90 $46.60 $69.90 $93.20 $93.20 $0.00 5010509 TELEMED CRIT CARE ADDITIONAL 50 MIN $441.00 G0509 780 8/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $220.50 $66.15 $44.10 $66.15 $88.20 $88.20 $0.00 5013014 TELEMED SITE FEE $75.00 Q3014 450 8/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 6629075 APPLICATION SHORT ARM CAST $237.00 29075 450 12/1/2021 zzLRMH_CC_Emergency $0.00 $0.00 $118.50 $35.55 $23.70 $35.55 $47.40 $47.40 $0.00 6629105 APPLICATION LONG ARM SPLINT $237.00 29105 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $118.50 $35.55 $23.70 $35.55 $47.40 $47.40 $0.00 6629125 APPLICATION SHORT ARM SPLINT $200.00 29125 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $100.00 $30.00 $20.00 $30.00 $40.00 $40.00 $0.00 6636000 SALINE LOCK $36.00 36000 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 6696372 IM/SQ INJECTION $66.00 96372 260 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $33.00 $9.90 $6.60 $9.90 $13.20 $13.20 $0.00 6699201 OFFICE/OUTPATIENT VISIT NEW 10MIN $464.00 99201 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $232.00 $69.60 $46.40 $69.60 $92.80 $92.80 $0.00 6699202 OFFICE/OUTPATIENT VISIT NEW 20MIN $464.00 99202 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $232.00 $69.60 $46.40 $69.60 $92.80 $92.80 $0.00 6699203 OFFICE/OUTPATIENT VISIT NEW 30MIN $532.00 99203 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $266.00 $79.80 $53.20 $79.80 $106.40 $106.40 $0.00 6699204 OFFICE/OUTPATIENT VISIT NEW 45MIN $774.00 99204 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $387.00 $116.10 $77.40 $116.10 $154.80 $154.80 $0.00 6699205 OFFICE/OUTPATIENT VISIT NEW 60MIN $774.00 99205 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $387.00 $116.10 $77.40 $116.10 $154.80 $154.80 $0.00 7720520 REMOVAL FOREIGN BODY SIMPLE $679.00 20520 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $339.50 $101.85 $67.90 $101.85 $135.80 $135.80 $0.00 7730903 CONTROL OF NOSEBLEED ANTERIOR COMPLEX $247.00 30903 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $123.50 $37.05 $24.70 $37.05 $49.40 $49.40 $0.00 7751701 INSERTION BLADDER CATHETER $105.00 51701 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $52.50 $15.75 $10.50 $15.75 $21.00 $21.00 $0.00 7751702 INSERTION TEMPORARY BLADDER CATHETER $105.00 51702 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $52.50 $15.75 $10.50 $15.75 $21.00 $21.00 $0.00 7759414 DELIVERY OF PLACENTA (SEPERATE PROCEDUE) $500.00 59414 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $250.00 $75.00 $50.00 $75.00 $100.00 $100.00 $0.00 7765222 REMOVE FOREIGN BODY EYE CORNEAL $108.00 65222 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $54.00 $16.20 $10.80 $16.20 $21.60 $21.60 $0.00 7796376 INJECTION FOR DIAGNOSIS/THERAPY $83.00 96376 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $41.50 $12.45 $8.30 $12.45 $16.60 $16.60 $0.00 8199201 HOSPITAL OUTPATIENT VISIT- MEDICAID $100.00 G0463 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 8299201 HOSPITAL OUTPATIENT VISIT- COMMERCIAL $100.00 G0463 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 8399201 HOSPITAL OUTPATIENT VISIT- WORKMAN'S COM $100.00 G0463 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 8499201 HOSPITAL OUT PATIENT- SELF PAY $100.00 G0463 761 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 32319125 APPLY FOREARM SPLINT $237.00 29125 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $118.50 $35.55 $23.70 $35.55 $47.40 $47.40 $0.00 32513060 THORACOTOMY TRAY $50.00 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 32799211 SLEEP LAB FACILITY FEE $250.00 99211 760 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $125.00 $37.50 $25.00 $37.50 $50.00 $50.00 $0.00 50137195 THROMBOSIS CEREBRAL $395.00 37195 450 8/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $197.50 $59.25 $39.50 $59.25 $79.00 $79.00 $0.00 50192977 THROMBOSIS CORONARY "$1,546.00" 92977 480 8/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $773.00 $231.90 $154.60 $231.90 $309.20 $309.20 $0.00 62029130 APPLICATION OF FINGER SPLINT S $43.00 29130 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 62029405 APPLICATION SHORT LEG CAST $263.00 29405 521 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $131.50 $39.45 $26.30 $39.45 $52.60 $52.60 $0.00 62029505 APPLICATION LONG LEG SPLINT $247.00 29505 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $123.50 $37.05 $24.70 $37.05 $49.40 $49.40 $0.00 62029515 APPLICATION SHORT LEG SPLINT $210.00 29515 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $105.00 $31.50 $21.00 $31.50 $42.00 $42.00 $0.00 62031500 INTUBATION-ENDOTRACHEAL $651.00 31500 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $325.50 $97.65 $65.10 $97.65 $130.20 $130.20 $0.00 303099201 OUT PT SHOT ROOM $78.00 99201 459 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $39.00 $11.70 $7.80 $11.70 $15.60 $15.60 $0.00 323110060 ER RM INCISION & DRAINAGE $501.00 10060 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $250.50 $75.15 $50.10 $75.15 $100.20 $100.20 $0.00 323110061 I & D MULTIPLE SITES $723.00 10061 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $361.50 $108.45 $72.30 $108.45 $144.60 $144.60 $0.00 323110080 "I & D PILONIDAL CYST, SIMPLE" $401.00 10080 450 11/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $200.50 $60.15 $40.10 $60.15 $80.20 $80.20 $0.00 323110120 ER RM INCISION & REMOVAL F B $503.00 10120 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $251.50 $75.45 $50.30 $75.45 $100.60 $100.60 $0.00 323110140 INCISION AND DRAINAGE OF HEMATOMA $278.00 10140 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $139.00 $41.70 $27.80 $41.70 $55.60 $55.60 $0.00 323110160 "ER RM PUNCTURE ASPIRATION, HEMATOMA, CYS" $327.00 10160 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $163.50 $49.05 $32.70 $49.05 $65.40 $65.40 $0.00 323111042 DEBRID SUBCUTANEOUS TISS FIRST 20CM $357.00 11042 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $178.50 $53.55 $35.70 $53.55 $71.40 $71.40 $0.00 323111104 PUNCH BIOPSY OF SKIN SINGLE LESION $182.00 11104 761 4/1/2020 zzLRMH_CC_Emergency $0.00 $0.00 $91.00 $27.30 $18.20 $27.30 $36.40 $36.40 $0.00 323111300 SHAVING OF SINGLE LESION 0.5CM OR LESS $145.00 11300 451 12/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $72.50 $21.75 $14.50 $21.75 $29.00 $29.00 $0.00 323111730 ER RM AVULSION NAIL PLATE $328.00 11730 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $164.00 $49.20 $32.80 $49.20 $65.60 $65.60 $0.00 323111740 ER RM EVACUATION SUBUNGUAL HEMATOMA $179.00 11740 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $89.50 $26.85 $17.90 $26.85 $35.80 $35.80 $0.00 323111750 EXCISION OF NAIL /MATREX PERMANENT REMOVAL $613.00 11750 450 11/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $306.50 $91.95 $61.30 $91.95 $122.60 $122.60 $0.00 323111765 "WEDGE EXC NAIL FOLD, INGROWN TOENA" $373.00 11765 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $186.50 $55.95 $37.30 $55.95 $74.60 $74.60 $0.00 323112001 ER RM LAC REP 2.5 CM OR LESS $252.00 12001 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $126.00 $37.80 $25.20 $37.80 $50.40 $50.40 $0.00 323112002 ER RM LAC REP 2.6-7.5CM $422.00 12002 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $211.00 $63.30 $42.20 $63.30 $84.40 $84.40 $0.00 323112004 ER RM LAC REP 7.6-12.5CM $521.00 12004 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $260.50 $78.15 $52.10 $78.15 $104.20 $104.20 $0.00 323112005 ER RM LAC REPAIR 12.6-20CM $665.00 12005 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $332.50 $99.75 $66.50 $99.75 $133.00 $133.00 $0.00 323112007 "SIMPLE REP. SUPERFICIAL WOUNDS OVER 30CM, EXC FACE, EARS, EYELIDS,NOSE, LIPS" $595.00 12007 450 9/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $297.50 $89.25 $59.50 $89.25 $119.00 $119.00 $0.00 323112011 ER RM LAC FACE 2.5CM OR LESS $501.00 12011 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $250.50 $75.15 $50.10 $75.15 $100.20 $100.20 $0.00 323112013 ER RM LAC REP FACE 2.6-5.0CM $689.00 12013 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $344.50 $103.35 $68.90 $103.35 $137.80 $137.80 $0.00 323112014 "SIMPLE REPAIR FACE 5.1CM-7.5CM ,EARS,EYELIDS,NOSE, LIPS" $320.00 12014 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $160.00 $48.00 $32.00 $48.00 $64.00 $64.00 $0.00 323112015 "ER RM LAC.REP 7.6CM-12.5CM FACE,EARS,EXT" $729.00 12015 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $364.50 $109.35 $72.90 $109.35 $145.80 $145.80 $0.00 323112016 "SIMPLE REP FACE, EARS, EYES, ECT 12.6-20.0CM" $548.00 12016 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $274.00 $82.20 $54.80 $82.20 $109.60 $109.60 $0.00 323112031 ER RM LAC REP INTERM 2.5CM OR LESS $657.00 12031 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $328.50 $98.55 $65.70 $98.55 $131.40 $131.40 $0.00 323112032 ER RM LAC REPAIR INT 2.6-7.5CM $657.00 12032 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $328.50 $98.55 $65.70 $98.55 $131.40 $131.40 $0.00 323112034 ER RM LAC REPAIR 7.6-12.5CM $825.00 12034 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $412.50 $123.75 $82.50 $123.75 $165.00 $165.00 $0.00 323112035 LAC REPAIR INTERM 12.6CM-20.0CM "$1,786.00" 12035 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $893.00 $267.90 $178.60 $267.90 $357.20 $357.20 $0.00 323112036 "ER RM LAC LAY CLOSE SCALP,TRNK 20.1-30CM" $890.00 12036 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $445.00 $133.50 $89.00 $133.50 $178.00 $178.00 $0.00 323112041 "REPAIR INTERM.HANDS,FEET ECT 2.5CM OR LESS" $605.00 12041 450 1/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $302.50 $90.75 $60.50 $90.75 $121.00 $121.00 $0.00 323112042 ER RM LAC LAY CLOS 2.6-7.5 CM $575.00 12042 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $287.50 $86.25 $57.50 $86.25 $115.00 $115.00 $0.00 323112044 "ER RM LAC LAY CLOS 7.6-12.5 SCALP,AXILL" $701.00 12044 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $350.50 $105.15 $70.10 $105.15 $140.20 $140.20 $0.00 323112045 "REP INT HANDS,NECK,FEET 12.6-20.0CM" "$1,080.00" 12045 450 11/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $540.00 $162.00 $108.00 $162.00 $216.00 $216.00 $0.00 323112051 "REP, LAC OF FACE 2.5CM OR LESS" $600.00 12051 451 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $300.00 $90.00 $60.00 $90.00 $120.00 $120.00 $0.00 323112052 "ER RM LAC LAY CLOS FACE,EAR 2.6-5.0CM" $585.00 12052 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $292.50 $87.75 $58.50 $87.75 $117.00 $117.00 $0.00 323112053 "INT REPAIR FACE, EARS, NOSE 5.1 TO7.5CM" $834.00 12053 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $417.00 $125.10 $83.40 $125.10 $166.80 $166.80 $0.00 323113121 "REPAIR COMPLEX 2.6-7.5CM, SCALP,ARMS OR LEGS" "$1,075.00" 13121 450 1/1/2020 zzLRMH_CC_Emergency $0.00 $0.00 $537.50 $161.25 $107.50 $161.25 $215.00 $215.00 $0.00 323113122 EA ADD 5CM OR LESS $345.00 13122 450 7/1/2020 zzLRMH_CC_Emergency $0.00 $0.00 $172.50 $51.75 $34.50 $51.75 $69.00 $69.00 $0.00 323113132 "REPAIR COMPLEX 2.6-7.5CM FACIAL, HANDS, FEET" "$1,270.00" 13132 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $635.00 $190.50 $127.00 $190.50 $254.00 $254.00 $0.00 323113133 "EA ADD 5CM OR LESS COMPLEX FOREHEAD, CHEEK, CHIN, HAND" $532.00 13133 450 3/1/2020 zzLRMH_CC_Emergency $0.00 $0.00 $266.00 $79.80 $53.20 $79.80 $106.40 $106.40 $0.00 323113151 "REPAIR COMPLEX,EYELIDS,EARS,LIPS 1.1CM-2.5CM" "$1,157.00" 13151 450 3/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $578.50 $173.55 $115.70 $173.55 $231.40 $231.40 $0.00 323113152 "LAC REP COMPLEX 2.6-7.5CM LIPS,EARS,NOSE" $819.00 13152 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $409.50 $122.85 $81.90 $122.85 $163.80 $163.80 $0.00 323116020 DEBRIDEMENT BURN SMALL $365.00 16020 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $182.50 $54.75 $36.50 $54.75 $73.00 $73.00 $0.00 323117250 CHEMICAL CAUTERIZATION $165.00 17250 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $82.50 $24.75 $16.50 $24.75 $33.00 $33.00 $0.00 323120552 ER RM TRIGGER POINT INJ 1-2 MU $399.00 20552 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $199.50 $59.85 $39.90 $59.85 $79.80 $79.80 $0.00 323120553 ER RM TRIGGER POINT INJECTION 3+ $450.00 20553 450 9/1/2023 zzLRMH_CC_Emergency $0.00 $0.00 $225.00 $67.50 $45.00 $67.50 $90.00 $90.00 $0.00 323120605 ER RM ASP/INJ MED JOINT $482.00 20605 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $241.00 $72.30 $48.20 $72.30 $96.40 $96.40 $0.00 323120610 ER RM ASP/INJ MAJOR JOINT $406.00 20610 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $203.00 $60.90 $40.60 $60.90 $81.20 $81.20 $0.00 323120612 ASPIRATION OF CYST $243.00 20612 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $121.50 $36.45 $24.30 $36.45 $48.60 $48.60 $0.00 323123650 ER RM SHOULDER W MANIPULATION $994.00 23650 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $497.00 $149.10 $99.40 $149.10 $198.80 $198.80 $0.00 323124600 "TREATMENT OF ELBOW DISLOCATION, W MANIPU" $334.00 24600 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $167.00 $50.10 $33.40 $50.10 $66.80 $66.80 $0.00 323124640 CLOSED TREAT RADIAL HEAD W MANIPULATION $535.00 24640 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $267.50 $80.25 $53.50 $80.25 $107.00 $107.00 $0.00 323125605 CLOSED TREATMENT DISTAL RADIAL FRACTURE W MANIPULATION "$1,179.00" 25605 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $589.50 $176.85 $117.90 $176.85 $235.80 $235.80 $0.00 323126070 INCISION & REMOVAL OF FOREIGN BODYOF HAND $600.00 26070 450 2/1/2022 zzLRMH_CC_Emergency $0.00 $0.00 $300.00 $90.00 $60.00 $90.00 $120.00 $120.00 $0.00 323126075 ER RM FM REMOVAL FINGER OR HAND JOINT $420.00 26075 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $210.00 $63.00 $42.00 $63.00 $84.00 $84.00 $0.00 323126742 ER RM FX FINGER CL TREATMENT W/MANIP $116.00 26742 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $58.00 $17.40 $11.60 $17.40 $23.20 $23.20 $0.00 323126755 CLOSED TREAT OF DISTAL PHALANGEAL FX FINGER OR THUMB W MANIPULATION "$1,080.00" 26755 450 6/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $540.00 $162.00 $108.00 $162.00 $216.00 $216.00 $0.00 323126770 ER RM PHALANGEAL DIS W MANIP "$1,000.00" 26770 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $500.00 $150.00 $100.00 $150.00 $200.00 $200.00 $0.00 323127550 CLOSED TREATMENT KNEE DISLOCATION WITH MANIPULATION $600.00 27550 450 7/1/2021 zzLRMH_CC_Emergency $0.00 $0.00 $300.00 $90.00 $60.00 $90.00 $120.00 $120.00 $0.00 323128190 ER RM REMOVAL FB FT SUBQ "$1,278.00" 28190 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $639.00 $191.70 $127.80 $191.70 $255.60 $255.60 $0.00 323128515 CLOSED TREATMENT OF FRACTURE PHALANGES $570.00 28515 450 8/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $285.00 $85.50 $57.00 $85.50 $114.00 $114.00 $0.00 323129075 APPLICATION OF SHORT ARM CAST $237.00 29075 450 12/1/2021 zzLRMH_CC_Emergency $0.00 $0.00 $118.50 $35.55 $23.70 $35.55 $47.40 $47.40 $0.00 323129580 UNNA BOOT APLICATION $148.00 29580 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $74.00 $22.20 $14.80 $22.20 $29.60 $29.60 $0.00 323130300 ER RM FB REMOVAL INTRANASAL $633.00 30300 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $316.50 $94.95 $63.30 $94.95 $126.60 $126.60 $0.00 323130901 ER RM CONTROL NOSEBLEED-SIMPLE ANTERIOR $557.00 30901 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $278.50 $83.55 $55.70 $83.55 $111.40 $111.40 $0.00 323130905 "CONTROL OF NOSEBLEED POSTERIOR, INITIAL" $600.00 30905 450 4/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $300.00 $90.00 $60.00 $90.00 $120.00 $120.00 $0.00 323131603 TRACHEOSTOMY EMERGENCY PROCEDURE $945.00 31603 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $472.50 $141.75 $94.50 $141.75 $189.00 $189.00 $0.00 323132551 ER RM CHEST TUBE INSERTION "$1,454.00" 32551 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $727.00 $218.10 $145.40 $218.10 $290.80 $290.80 $0.00 323136556 ER RM CENTRAL LINE PLACEMENT $873.00 36556 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $436.50 $130.95 $87.30 $130.95 $174.60 $174.60 $0.00 323136589 REMOVAL OF PICC LINE "$1,167.00" 36589 510 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $583.50 $175.05 $116.70 $175.05 $233.40 $233.40 $0.00 323136680 PLACEMENT OF NEEDLE INTEROSSEOUS $526.00 36680 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $263.00 $78.90 $52.60 $78.90 $105.20 $105.20 $0.00 323141250 ER RM LAC TONGUE 2.5 OR LESS $350.00 41250 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $175.00 $52.50 $35.00 $52.50 $70.00 $70.00 $0.00 323143753 "ER RM GASTRIC INT, &LAVAGE" $191.00 43753 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $95.50 $28.65 $19.10 $28.65 $38.20 $38.20 $0.00 323143760 REPLACE GASTROSTOMY TUBE $193.00 43762 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $96.50 $28.95 $19.30 $28.95 $38.60 $38.60 $0.00 323146083 ER RM INCISION THROMBOSED HEMORRHOID EXT $351.00 46083 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $175.50 $52.65 $35.10 $52.65 $70.20 $70.20 $0.00 323151700 BLADDER IRRIGATION $128.00 51700 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $64.00 $19.20 $12.80 $19.20 $25.60 $25.60 $0.00 323159409 VAGINAL DELIVERY $500.00 59409 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $250.00 $75.00 $50.00 $75.00 $100.00 $100.00 $0.00 323164400 "NERVE BLOCK AND TRANSFORAMINAL INJECTION OPHTHALMIC, MAXILLARY, MANDIBULAR" $251.00 64400 450 11/1/2023 zzLRMH_CC_Emergency $0.00 $0.00 $125.50 $37.65 $25.10 $37.65 $50.20 $50.20 $0.00 323165205 ER RM REMOVAL FB EYE CONJUNCTI $427.00 65205 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $213.50 $64.05 $42.70 $64.05 $85.40 $85.40 $0.00 323165220 ER RM REM F/B CORNEA EXT $76.00 65220 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $38.00 $11.40 $7.60 $11.40 $15.20 $15.20 $0.00 323165222 REMOVAL FOREIGN BODY CORNEA EYE $108.00 65222 450 11/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $54.00 $16.20 $10.80 $16.20 $21.60 $21.60 $0.00 323169000 "DRAINAGE EXTERNAL EAR, HEMATOMA, SIMPLE" $278.00 69000 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $139.00 $41.70 $27.80 $41.70 $55.60 $55.60 $0.00 323169200 ER RM REMOVAL FB EAR CANAL ER RM $69.00 69200 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $34.50 $10.35 $6.90 $10.35 $13.80 $13.80 $0.00 323169209 "ER RM EAR IRRIGATION WITHOUT INSTRUMENTATION " $250.00 69209 450 9/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $125.00 $37.50 $25.00 $37.50 $50.00 $50.00 $0.00 323169210 ER RM EAR IRRIGATION WITH INSTRUMENTATION $275.00 69210 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $137.50 $41.25 $27.50 $41.25 $55.00 $55.00 $0.00 323192950 CARDIOPULMONARY RESUSCITATION $400.00 92950 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $200.00 $60.00 $40.00 $60.00 $80.00 $80.00 $0.00 323192960 CARDIOVERSION EXTERNAL $412.00 92960 450 1/1/2021 zzLRMH_CC_Emergency $0.00 $0.00 $206.00 $61.80 $41.20 $61.80 $82.40 $82.40 $0.00 323192977 THROMBOLYTIC THERAPY TNKASE $158.00 92977 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $79.00 $23.70 $15.80 $23.70 $31.60 $31.60 $0.00 323199211 TREATMENT ROOM $53.00 99211 760 5/1/2020 zzLRMH_CC_Emergency $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 323199292 CRITICAL CARE EA ADD 30 MIN "$1,033.00" 99292 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $516.50 $154.95 $103.30 $154.95 $206.60 $206.60 $0.00 323199381 DHS PHYSICAL AGE YOUNGER THAN 1 YEAR $100.00 99381 450 3/26/2020 zzLRMH_CC_Emergency $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 323199382 DHS PHYSICAL 1-4 YEARS $150.00 99383 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $75.00 $22.50 $15.00 $22.50 $30.00 $30.00 $0.00 323199383 DHS PHYSICAL 5-11 YEARS $160.00 99383 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $80.00 $24.00 $16.00 $24.00 $32.00 $32.00 $0.00 323199384 DHS PHYSICAL 12-17 YEARS $189.00 99384 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $94.50 $28.35 $18.90 $28.35 $37.80 $37.80 $0.00 407126755 CLOSED TREATMENT DISTAL PHALANGEAL FX FINGER OR THUMB W MANIPULATION "$1,080.00" 26755 450 6/1/2019 zzLRMH_CC_Emergency $0.00 $0.00 $540.00 $162.00 $108.00 $162.00 $216.00 $216.00 $0.00 407236680 ER RM PLACEMENT NEEDLE FOR IO INFUS $526.00 36680 450 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $263.00 $78.90 $52.60 $78.90 $105.20 $105.20 $0.00 461297605 NEGATIVE PRESSURE WOUND <=50SQ $890.00 97605 361 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $445.00 $133.50 $89.00 $133.50 $178.00 $178.00 $0.00 461299135 CHEMICAL CAUTERIZATION GRAN TI $580.00 17250 361 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $290.00 $87.00 $58.00 $87.00 $116.00 $116.00 $0.00 461299336 "DEBRIDE,SUBQ TISSUE 1ST 20CM" $998.00 11042 361 7/1/2018 zzLRMH_CC_Emergency $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 AL12345 ER RM INCISION & DRAINAGE $501.00 10060 761 1/1/2022 zzLRMH_CC_Emergency $0.00 $0.00 $250.50 $75.15 $50.10 $75.15 $100.20 $100.20 $0.00 2126 TESTOSTERONE $164.00 84403 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $82.00 $24.60 $16.40 $24.60 $32.80 $32.80 $0.00 2140 RENAL FUNCTION PANEL $141.00 80069 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $70.50 $21.15 $14.10 $21.15 $28.20 $28.20 $0.00 21107 ANTIBODY SCREENING $100.00 86850 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 21133 T4 - TOTAL THYROXINE $76.00 84436 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $38.00 $11.40 $7.60 $11.40 $15.20 $15.20 $0.00 21140 LIVER PANEL $134.00 80076 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $67.00 $20.10 $13.40 $20.10 $26.80 $26.80 $0.00 21160 ELECTROLYTES SERUM $94.00 80051 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $47.00 $14.10 $9.40 $14.10 $18.80 $18.80 $0.00 21170 GLUCOSE SERUM $46.00 82947 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $23.00 $6.90 $4.60 $6.90 $9.20 $9.20 $0.00 21203 CA-125 $150.00 86304 302 1/1/2017 zzLRMH_CC_Lab $0.00 $0.00 $75.00 $22.50 $15.00 $22.50 $30.00 $30.00 $0.00 21205 H.PLYORI $121.00 86677 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $60.50 $18.15 $12.10 $18.15 $24.20 $24.20 $0.00 21290 BILIRUBIN DIRECT $53.00 82248 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 21300 BILIRUBIN TOTAL $53.00 82247 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 21320 BLOOD TYPE $150.00 86900 309 8/22/2019 zzLRMH_CC_Lab $0.00 $0.00 $75.00 $22.50 $15.00 $22.50 $30.00 $30.00 $0.00 21321 RH FACTOR - BLOOD $52.00 86901 300 8/22/2019 zzLRMH_CC_Lab $0.00 $0.00 $26.00 $7.80 $5.20 $7.80 $10.40 $10.40 $0.00 21330 CROSSMATCH/UNIT $130.00 86920 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $65.00 $19.50 $13.00 $19.50 $26.00 $26.00 $0.00 21340 COOMBS DIRECT (IGG) $66.00 86880 305 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $33.00 $9.90 $6.60 $9.90 $13.20 $13.20 $0.00 21370 CULTURE - URINE $92.00 87086 306 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $46.00 $13.80 $9.20 $13.80 $18.40 $18.40 $0.00 21375 CULTURE - THROAT $114.00 87070 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 21450 OCCULT BLOOD $37.00 82272 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $18.50 $5.55 $3.70 $5.55 $7.40 $7.40 $0.00 21460 URINALYSIS $46.00 81000 307 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $23.00 $6.90 $4.60 $6.90 $9.20 $9.20 $0.00 21470 CHEMICAL URINALYSIS (DIP STIX) $60.00 81002 307 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $30.00 $9.00 $6.00 $9.00 $12.00 $12.00 $0.00 21480 URINE MICROSCOPIC $43.00 81015 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 21490 PREGNANCY TEST SERUM $101.00 84703 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $50.50 $15.15 $10.10 $15.15 $20.20 $20.20 $0.00 21500 CBC W/AUTODIF $90.00 85025 300 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $45.00 $13.50 $9.00 $13.50 $18.00 $18.00 $0.00 21540 CK $75.00 82550 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 21600 AMYLASE $90.00 82150 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $45.00 $13.50 $9.00 $13.50 $18.00 $18.00 $0.00 21640 PHENOBARITAL $123.00 80184 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $61.50 $18.45 $12.30 $18.45 $24.60 $24.60 $0.00 21660 PHENYTOIN (DILANTIN) $128.00 80185 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $64.00 $19.20 $12.80 $19.20 $25.60 $25.60 $0.00 21680 GRAM STAIN $55.00 87205 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 21690 WET PREP $59.00 87210 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $29.50 $8.85 $5.90 $8.85 $11.80 $11.80 $0.00 21710 RED BLOOD COUNT (RBC) $28.00 85041 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 21720 HEMOGLOBIN $34.00 85018 305 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $17.00 $5.10 $3.40 $5.10 $6.80 $6.80 $0.00 21730 HEMATOCRIT $34.00 85014 305 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $17.00 $5.10 $3.40 $5.10 $6.80 $6.80 $0.00 21760 PLATELET COUNT $53.00 85049 305 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 21770 SEDRATE $52.00 85651 305 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $26.00 $7.80 $5.20 $7.80 $10.40 $10.40 $0.00 21810 PRO TIME (PT) $55.00 85610 300 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 21820 PTT $77.00 85730 305 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $38.50 $11.55 $7.70 $11.55 $15.40 $15.40 $0.00 21997 HEPATITIS B SUR ANTIBODY $93.00 86706 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $46.50 $13.95 $9.30 $13.95 $18.60 $18.60 $0.00 87902 HEPATITIS C GEN $842.00 87902 306 12/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $421.00 $126.30 $84.20 $126.30 $168.40 $168.40 $0.00 211071 GENTAMICIN TROUGH $152.00 80170 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 211072 GENTAMICIN PEAK $152.00 80170 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 211130 THEOPHYLLINE $127.00 80198 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $63.50 $19.05 $12.70 $19.05 $25.40 $25.40 $0.00 211172 TRIGLYCERIDES $59.00 84478 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $29.50 $8.85 $5.90 $8.85 $11.80 $11.80 $0.00 211290 H D L $65.00 83718 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $32.50 $9.75 $6.50 $9.75 $13.00 $13.00 $0.00 211339 "IRON, SERUM" $64.00 83540 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 211347 TIBC $75.00 83550 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 211453 "HEMOGLOBIN, A1C" $88.00 83036 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $44.00 $13.20 $8.80 $13.20 $17.60 $17.60 $0.00 211487 ELECTROPHORESIS SERUM PROTEIN- $98.00 84165 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $49.00 $14.70 $9.80 $14.70 $19.60 $19.60 $0.00 211503 VITAMIN B-12 $119.00 82607 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $59.50 $17.85 $11.90 $17.85 $23.80 $23.80 $0.00 211511 HEMOGLOBIN ELECTROPHORESIS $111.00 83021 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $55.50 $16.65 $11.10 $16.65 $22.20 $22.20 $0.00 211537 MAGNESIUM SERUM $73.00 83735 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $36.50 $10.95 $7.30 $10.95 $14.60 $14.60 $0.00 211612 ALKALINE PHOSPHATE ISO(AIPISO) $90.00 84075 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $45.00 $13.50 $9.00 $13.50 $18.00 $18.00 $0.00 211776 IGG $104.00 82784 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $52.00 $15.60 $10.40 $15.60 $20.80 $20.80 $0.00 211974 FREE T4 $102.00 84439 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $51.00 $15.30 $10.20 $15.30 $20.40 $20.40 $0.00 212006 RENIN (PLASMA) $139.00 84244 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $69.50 $20.85 $13.90 $20.85 $27.80 $27.80 $0.00 212014 FOLIC ACID $115.00 82746 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $57.50 $17.25 $11.50 $17.25 $23.00 $23.00 $0.00 212021 URINE PREGNANCY TEST $78.00 81025 307 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $39.00 $11.70 $7.80 $11.70 $15.60 $15.60 $0.00 212040 TOTAL PROTEIN (URINE) $59.00 84156 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $29.50 $8.85 $5.90 $8.85 $11.80 $11.80 $0.00 212071 OSMOLALITY SERUM $79.00 83930 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 212121 "HEPATITIS DIAGNOSTIC PANEL " $333.00 80074 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $166.50 $49.95 $33.30 $49.95 $66.60 $66.60 $0.00 212139 CARCINOEMBRONIC ANTIGEN (CEA) $152.00 82378 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 212170 "IGE, QN" $105.00 82785 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $52.50 $15.75 $10.50 $15.75 $21.00 $21.00 $0.00 212253 ALPHA-FETOPROTEIN (AFP) $123.00 82105 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $61.50 $18.45 $12.30 $18.45 $24.60 $24.60 $0.00 212459 TSH (THYROID STIMULATING HORMN $137.00 84443 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $68.50 $20.55 $13.70 $20.55 $27.40 $27.40 $0.00 213012 CREATININE - URINE $12.50 82570 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $6.25 $1.88 $1.25 $1.88 $2.50 $2.50 $0.00 213178 "SODIUM, URINE" $58.00 84300 300 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $29.00 $8.70 $5.80 $8.70 $11.60 $11.60 $0.00 213186 POTASSIUM URINE $56.00 84133 300 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $28.00 $8.40 $5.60 $8.40 $11.20 $11.20 $0.00 213277 TOTAL PROTEIN (24 HR URINE) $59.00 84156 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $29.50 $8.85 $5.90 $8.85 $11.80 $11.80 $0.00 213442 OSMOLALITY URINE $77.00 83935 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $38.50 $11.55 $7.70 $11.55 $15.40 $15.40 $0.00 214051 CORTISOL $135.00 82533 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $67.50 $20.25 $13.50 $20.25 $27.00 $27.00 $0.00 214143 VANILLYLMANDELIC (VMA) $113.00 84585 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 214176 CATECHOLAMINE/FRACT URINE $165.00 82382 307 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $82.50 $24.75 $16.50 $24.75 $33.00 $33.00 $0.00 214234 METANEPHRINES 24 HR URINE $164.00 83835 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $82.00 $24.60 $16.40 $24.60 $32.80 $32.80 $0.00 214275 GROWTH HORMONE $100.00 83003 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 214291 ALDOSTERONE URINE $208.00 82088 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $104.00 $31.20 $20.80 $31.20 $41.60 $41.60 $0.00 214309 FSH $141.00 83001 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $70.50 $21.15 $14.10 $21.15 $28.20 $28.20 $0.00 214317 PROGESTERONE $133.00 84144 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $66.50 $19.95 $13.30 $19.95 $26.60 $26.60 $0.00 214333 INSULIN ( 1 SPECIMEN) $86.00 83525 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $43.00 $12.90 $8.60 $12.90 $17.20 $17.20 $0.00 214374 "ALDOSTERONE, PLASMA" $208.00 82088 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $104.00 $31.20 $20.80 $31.20 $41.60 $41.60 $0.00 214416 BHCG QUANTITIVE $100.00 84702 301 10/1/2020 zzLRMH_CC_Lab $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 214440 ACTH $427.00 82024 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $213.50 $64.05 $42.70 $64.05 $85.40 $85.40 $0.00 214465 PROLACTIN $244.00 84146 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $122.00 $36.60 $24.40 $36.60 $48.80 $48.80 $0.00 214484 TROPONIN QUALITIVE $149.00 84512 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $74.50 $22.35 $14.90 $22.35 $29.80 $29.80 $0.00 214515 ESTRADIOL $98.00 82670 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $49.00 $14.70 $9.80 $14.70 $19.60 $19.60 $0.00 214549 "ESTROGENS, TOTAL" $273.00 82672 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $136.50 $40.95 $27.30 $40.95 $54.60 $54.60 $0.00 214598 FERRITIN $89.00 82728 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 214697 DHEA SULFATE $194.00 82627 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $97.00 $29.10 $19.40 $29.10 $38.80 $38.80 $0.00 214770 LACTIC ACID $83.00 83605 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $41.50 $12.45 $8.30 $12.45 $16.60 $16.60 $0.00 214804 "CALCIUM, IONIZED" $184.00 82330 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $92.00 $27.60 $18.40 $27.60 $36.80 $36.80 $0.00 214880 DRUG SCREEN (SERUM) 5ML $475.00 80299 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $237.50 $71.25 $47.50 $71.25 $95.00 $95.00 $0.00 214881 DRUG SCREEN-IN HOUSE $42.00 80305 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $21.00 $6.30 $4.20 $6.30 $8.40 $8.40 $0.00 214887 SERUM/URINE KETONE $102.00 82009 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $51.00 $15.30 $10.20 $15.30 $20.40 $20.40 $0.00 214937 TRANSFERRIN $148.00 84466 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $74.00 $22.20 $14.80 $22.20 $29.60 $29.60 $0.00 214945 PARATHYROID HORMONE INTACT $182.00 83970 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $91.00 $27.30 $18.20 $27.30 $36.40 $36.40 $0.00 215231 "CELL COUNT, BODY FLUIDS" $158.00 89051 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $79.00 $23.70 $15.80 $23.70 $31.60 $31.60 $0.00 215280 RETICULOCYTE COUNT $76.00 85045 305 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $38.00 $11.40 $7.60 $11.40 $15.20 $15.20 $0.00 215590 DIGOXIN $176.00 80162 300 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $88.00 $26.40 $17.60 $26.40 $35.20 $35.20 $0.00 215595 FREE HEMOGOLBIN PLASMA $125.00 83051 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $62.50 $18.75 $12.50 $18.75 $25.00 $25.00 $0.00 216031 ASO TITER $98.00 86060 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $49.00 $14.70 $9.80 $14.70 $19.60 $19.60 $0.00 216072 RPR $29.00 86592 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $14.50 $4.35 $2.90 $4.35 $5.80 $5.80 $0.00 216189 MONO TEST $122.00 86308 302 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $61.00 $18.30 $12.20 $18.30 $24.40 $24.40 $0.00 216379 "FTA , ABS" $240.00 86780 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $120.00 $36.00 $24.00 $36.00 $48.00 $48.00 $0.00 216502 RA FACTOR (QUANT) $64.00 86431 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 216510 HEPATITIS B SURFACE ANTIGEN $114.00 87340 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 216619 HEPATITIS BE AG $288.00 87350 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $144.00 $43.20 $28.80 $43.20 $57.60 $57.60 $0.00 216627 CRP (C-REACTIVE PROTEIN) $110.00 86140 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $55.00 $16.50 $11.00 $16.50 $22.00 $22.00 $0.00 216643 ANTI-SMOOTH-MUSCLE (ACTIN) $116.00 83516 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $58.00 $17.40 $11.60 $17.40 $23.20 $23.20 $0.00 216676 THYROID PEROXIDASE (TPO) AB $138.00 86376 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $69.00 $20.70 $13.80 $20.70 $27.60 $27.60 $0.00 216692 THYROGLOBULIN AB. $276.00 86800 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $138.00 $41.40 $27.60 $41.40 $55.20 $55.20 $0.00 216866 ROTAVIRUS EIA $160.00 87425 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $80.00 $24.00 $16.00 $24.00 $32.00 $32.00 $0.00 216961 "METHYLMALONIC ACID, SERUM" $302.00 83921 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $151.00 $45.30 $30.20 $45.30 $60.40 $60.40 $0.00 216994 HOMOCYSTEINE SERUM $194.00 83090 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $97.00 $29.10 $19.40 $29.10 $38.80 $38.80 $0.00 217054 AMMONIA - PLASMA $25.00 82140 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 217260 DEPAKOTE (VALPORIC ACID) $184.00 80164 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $92.00 $27.60 $18.40 $27.60 $36.80 $36.80 $0.00 217419 CARBAMAZEPINE-SERUM (TEGRETOL) $213.00 80156 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $106.50 $31.95 $21.30 $31.95 $42.60 $42.60 $0.00 217625 "LEAD, BLOOD" $74.00 83655 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $37.00 $11.10 $7.40 $11.10 $14.80 $14.80 $0.00 217691 SALICYLATE $119.00 80179 301 1/1/2021 zzLRMH_CC_Lab $0.00 $0.00 $59.50 $17.85 $11.90 $17.85 $23.80 $23.80 $0.00 217708 LITHIUM LEVEL $80.00 80178 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $40.00 $12.00 $8.00 $12.00 $16.00 $16.00 $0.00 217856 PRIMIDONE (MYSOLINE) $123.00 80188 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $61.50 $18.45 $12.30 $18.45 $24.60 $24.60 $0.00 218045 CLOSTRIDIUM DIFFICILE TOXIN $137.00 87230 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $68.50 $20.55 $13.70 $20.55 $27.40 $27.40 $0.00 218136 KOH - PREP FUNGUS $59.00 87210 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $29.50 $8.85 $5.90 $8.85 $11.80 $11.80 $0.00 218219 PARASITE ID WORM $47.00 87169 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $23.50 $7.05 $4.70 $7.05 $9.40 $9.40 $0.00 218334 CULTURE GENITAL $79.00 87070 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 218482 CULTURE FUNGUS $130.00 87102 307 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $65.00 $19.50 $13.00 $19.50 $26.00 $26.00 $0.00 218573 "VIRAL CULTURE,GENERAL" $183.00 87252 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $91.50 $27.45 $18.30 $27.45 $36.60 $36.60 $0.00 218623 OVA & PARASITE $88.00 87177 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $44.00 $13.20 $8.80 $13.20 $17.60 $17.60 $0.00 218649 CULTURE SPUTUM $114.00 87070 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 218656 WBC - STOOL $55.00 89055 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 218904 CULTURE AEROBIC $114.00 87070 309 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 219068 URINE CYTOLOGY $147.00 88112 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 219077 CYTOLOGY - MISCELLANEOUS FLUID $147.00 88305 310 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 219100 PAP SMEAR (LIQUID BASED) $76.00 88164 311 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $38.00 $11.40 $7.60 $11.40 $15.20 $15.20 $0.00 219803 COVID COLLECTION FEE OP/IP $75.00 C9803 300 2/4/2020 zzLRMH_CC_Lab $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 303510 PHLEBOTOMY - THERAPEUTIC $98.00 99195 940 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $49.00 $14.70 $9.80 $14.70 $19.60 $19.60 $0.00 1660802 "COPPER, SERUM OR PLASMA" $87.00 82525 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 2101529 "CAROTENE, BETA" $132.00 82380 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $66.00 $19.80 $13.20 $19.80 $26.40 $26.40 $0.00 2107654 "ETHYLENE GLYCOL, SERUM" $50.00 82693 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 2110000 BMP $132.00 80048 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $66.00 $19.80 $13.20 $19.80 $26.40 $26.40 $0.00 2110001 CHLAMYDIA DNA PROB $62.00 87491 306 11/7/2018 zzLRMH_CC_Lab $0.00 $0.00 $31.00 $9.30 $6.20 $9.30 $12.40 $12.40 $0.00 2110108 C-PEPTIDE (PROINSULIN) $122.00 84681 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $61.00 $18.30 $12.20 $18.30 $24.40 $24.40 $0.00 2110314 "THYROTROPIN RECEPTOR ANTIBODY, SERUM" $198.00 83520 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $99.00 $29.70 $19.80 $29.70 $39.60 $39.60 $0.00 2110322 "PSA TOTAL, DIAGNOSTIC" $133.00 84153 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $66.50 $19.95 $13.30 $19.95 $26.60 $26.60 $0.00 2110363 IGF QUANTITATIVE - SERUM $137.00 84305 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $68.50 $20.55 $13.70 $20.55 $27.40 $27.40 $0.00 2110389 FREE T3 $137.00 84481 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $68.50 $20.55 $13.70 $20.55 $27.40 $27.40 $0.00 2111114 HIV I SCREEN $109.00 86703 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $54.50 $16.35 $10.90 $16.35 $21.80 $21.80 $0.00 2111586 COOPER URINE $87.00 82525 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 2111587 "COPPER, SERUM OR PLASMA" $87.00 82525 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 2114040 LIPASE $94.00 83690 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $47.00 $14.10 $9.40 $14.10 $18.80 $18.80 $0.00 2114917 CMP $178.00 80053 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $89.00 $26.70 $17.80 $26.70 $35.60 $35.60 $0.00 2114919 TULAREMIA AGGLUTININS $101.00 86668 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.50 $15.15 $10.10 $15.15 $20.20 $20.20 $0.00 2114920 LYME AB IFA (TITER) $124.00 86618 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $62.00 $18.60 $12.40 $18.60 $24.80 $24.80 $0.00 2114922 ALCOHOL SERUM $152.00 80320 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 2115003 "CREATINE, CLEARANCE" $109.00 82575 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $54.50 $16.35 $10.90 $16.35 $21.80 $21.80 $0.00 2115005 CULTURE STOOL $113.00 87045 309 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 2115008 CPK $87.00 82552 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 2115009 CKMB $87.00 82553 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 2115057 ANTITHROMBIN III AG $113.00 85301 305 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 2115060 COLLECTION FEE $26.00 99001 300 7/15/2020 zzLRMH_CC_Lab $0.00 $0.00 $13.00 $3.90 $2.60 $3.90 $5.20 $5.20 $0.00 2115188 D-DIMER $248.00 85379 305 6/30/2020 zzLRMH_CC_Lab $0.00 $0.00 $124.00 $37.20 $24.80 $37.20 $49.60 $49.60 $0.00 2115402 FIBRINOGEN $113.00 85384 305 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 2116667 ROCKY MOUNTAIN SPOTTED FEVER IGM $101.00 86757 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.50 $15.15 $10.10 $15.15 $20.20 $20.20 $0.00 2116931 PREALBUMIN $101.00 84134 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.50 $15.15 $10.10 $15.15 $20.20 $20.20 $0.00 2117323 TOBRAMYCIN PEAK $145.00 80200 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $72.50 $21.75 $14.50 $21.75 $29.00 $29.00 $0.00 2117324 TOBRAMYCIN TROUGH $145.00 80200 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $72.50 $21.75 $14.50 $21.75 $29.00 $29.00 $0.00 2117608 CULTURE BLOOD $153.00 87040 309 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $76.50 $22.95 $15.30 $22.95 $30.60 $30.60 $0.00 2120790 "CALCULI, URINARY W/PHOTGRAPH" $109.00 82360 307 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $54.50 $16.35 $10.90 $16.35 $21.80 $21.80 $0.00 2121085 CMV ABS IGG $100.00 86644 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 2121186 THIAMINE (VITAMIN B1) $133.00 84425 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $66.50 $19.95 $13.30 $19.95 $26.60 $26.60 $0.00 2122110 PERIPHERAL SMEAR $105.00 85060 310 10/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $52.50 $15.75 $10.50 $15.75 $21.00 $21.00 $0.00 2123503 LIPID PROFILE 4 $131.00 80061 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $65.50 $19.65 $13.10 $19.65 $26.20 $26.20 $0.00 2128480 FSH AND LSH $141.00 83001 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $70.50 $21.15 $14.10 $21.15 $28.20 $28.20 $0.00 2132763 HEAVY METAL URINE $178.00 82175 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $89.00 $26.70 $17.80 $26.70 $35.60 $35.60 $0.00 2133251 EHRLICHIOSIS $107.00 86666 302 11/7/2018 zzLRMH_CC_Lab $0.00 $0.00 $53.50 $16.05 $10.70 $16.05 $21.40 $21.40 $0.00 2133969 LDL DIRECT $66.00 83721 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $33.00 $9.90 $6.60 $9.90 $13.20 $13.20 $0.00 2136592 VENIPUNCTURE (PORT) $25.00 36592 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 2138842 WEST NILE AB $102.00 86788 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $51.00 $15.30 $10.20 $15.30 $20.40 $20.40 $0.00 2140049 T3 UPTAKE $70.00 84479 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $35.00 $10.50 $7.00 $10.50 $14.00 $14.00 $0.00 2140277 ERYTHROPOIENTIN $130.00 82668 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $65.00 $19.50 $13.00 $19.50 $26.00 $26.00 $0.00 2140472 HEPATITIS C ANTIBODY SCREENING $119.00 G0472 301 8/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $59.50 $17.85 $11.90 $17.85 $23.80 $23.80 $0.00 2140608 HEPATITIS C ANTIBODY $119.00 86803 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $59.50 $17.85 $11.90 $17.85 $23.80 $23.80 $0.00 2140889 B-TYPE-NATRIURETIC-PEPITIDE $209.00 83880 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $104.50 $31.35 $20.90 $31.35 $41.80 $41.80 $0.00 2140964 MYOGLOBIN - SERUM $124.00 83874 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $62.00 $18.60 $12.40 $18.60 $24.80 $24.80 $0.00 2143008 GAD - 65 $174.00 83519 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $87.00 $26.10 $17.40 $26.10 $34.80 $34.80 $0.00 2145534 PSA SCREENING $133.00 G0103 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $66.50 $19.95 $13.30 $19.95 $26.60 $26.60 $0.00 2146557 ADH - ANTI DIURETIC HORMONE $79.00 84588 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 2148010 THYROIDCALCITONIA (CALCITONIN) $154.00 82308 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $77.00 $23.10 $15.40 $23.10 $30.80 $30.80 $0.00 2148364 CULTURE OTHER $114.00 87070 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 2149997 MICROALBUMIN (RANDOM) $12.50 82043 309 9/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $6.25 $1.88 $1.25 $1.88 $2.50 $2.50 $0.00 2153124 ZINC - URINE $78.00 84630 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $39.00 $11.70 $7.80 $11.70 $15.60 $15.60 $0.00 2153125 "ZINC, SERM OR PLAMSA" $111.00 84630 301 2/1/2020 zzLRMH_CC_Lab $0.00 $0.00 $55.50 $16.65 $11.10 $16.65 $22.20 $22.20 $0.00 2156500 DNA ANTIBODY NATIVE $114.00 86225 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 2156501 NUCLEAR (SJOGREN) ANTIGEN ANTIBODY $113.00 86235 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 2164509 RISTOCETIN COFACTOR - VWF $168.00 85245 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $84.00 $25.20 $16.80 $25.20 $33.60 $33.60 $0.00 2164517 PROTEIN S ANTIGEN $141.00 85306 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $70.50 $21.15 $14.10 $21.15 $28.20 $28.20 $0.00 2164905 HERP SIMPLEX I&II IGG $77.00 86695 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $38.50 $11.55 $7.70 $11.55 $15.40 $15.40 $0.00 2164988 TISSUE TRANSGLUTAMINASE ANTIBODIES IGG $100.00 83516 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 2170104 T3- REVERSE $101.00 84482 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.50 $15.15 $10.10 $15.15 $20.20 $20.20 $0.00 2170326 VANCOMYCIN LEVEL-SERUM $146.00 80202 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 2170327 VANCOMYCIN PEAK $146.00 80202 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 2170328 VANCOMYCIN TROUGH $146.00 80202 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 2171712 KLONOPIN (CLONAZEPAM) $115.00 80346 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $57.50 $17.25 $11.50 $17.25 $23.00 $23.00 $0.00 2180001 ALBUMIN $48.00 82040 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 2180004 CALCIUM SERUM $52.00 82310 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $26.00 $7.80 $5.20 $7.80 $10.40 $10.40 $0.00 2180006 CHOLESTEROL $51.00 82465 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $25.50 $7.65 $5.10 $7.65 $10.20 $10.20 $0.00 2180007 CREATININE $52.00 82565 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $26.00 $7.80 $5.20 $7.80 $10.40 $10.40 $0.00 2180009 LACTIC DEHYDROGENASE (LDH) $64.00 83615 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 2180011 ALK PHOS $53.00 84075 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 2180013 POTASSIUM SERUM $48.00 84132 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 2180015 SODIUM SERUM $48.00 84295 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 2180016 AST $56.00 84450 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $28.00 $8.40 $5.60 $8.40 $11.20 $11.20 $0.00 2180017 ALT $56.00 84460 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $28.00 $8.40 $5.60 $8.40 $11.20 $11.20 $0.00 2180018 BUN - UREA NITROGEN $48.00 84520 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 2180019 URIC ACID $55.00 84550 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 2180020 TOTAL PROTEIN (SERUM) $47.00 84155 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $23.50 $7.05 $4.70 $7.05 $9.40 $9.40 $0.00 2180021 GAMMA GT $68.00 82977 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 2180150 AMIKACIN TROUGH $374.00 80150 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $187.00 $56.10 $37.40 $56.10 $74.80 $74.80 $0.00 2180465 PROTEIN C ANTIGEN $140.00 85302 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $70.00 $21.00 $14.00 $21.00 $28.00 $28.00 $0.00 2180802 CULTURE BODY FLUID $114.00 87070 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 2182003 ACETAMINOPHEN-SERUM $194.00 80143 301 1/1/2021 zzLRMH_CC_Lab $0.00 $0.00 $97.00 $29.10 $19.40 $29.10 $38.80 $38.80 $0.00 2182204 GIARDIA - AG $87.00 87329 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 2182306 VITAMIN D 25I HYDROXY $167.00 82306 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $83.50 $25.05 $16.70 $25.05 $33.40 $33.40 $0.00 2182873 QUANTIFERON TB GOLD $108.00 86480 302 10/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $54.00 $16.20 $10.80 $16.20 $21.60 $21.60 $0.00 2182962 GLUCOSE BY MONITORING DEVICE $31.00 82962 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $15.50 $4.65 $3.10 $4.65 $6.20 $6.20 $0.00 2183824 HIV I/II W/CONFIRMATION $98.00 87389 302 8/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $49.00 $14.70 $9.80 $14.70 $19.60 $19.60 $0.00 2184075 PHOSPHORUS $53.00 84100 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 2184480 TRIIODOTHYRONINE - TOTAL T3 $114.00 84480 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 2184484 TROPONIN - I $149.00 84484 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $74.50 $22.35 $14.90 $22.35 $29.80 $29.80 $0.00 2185007 MANUAL DIFFERENTIAL $43.00 85009 300 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 2185008 RBC MOPHOLOGY $43.00 85008 305 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 2186173 "PERTUSSIS, SMEAR (DFA)" $96.00 87265 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $48.00 $14.40 $9.60 $14.40 $19.20 $19.20 $0.00 2186225 ANTI DNA DOUBLE STRAND $104.00 86225 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $52.00 $15.60 $10.40 $15.60 $20.80 $20.80 $0.00 2186615 PERTUSSIS ANTIBODIES $78.00 86615 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $39.00 $11.70 $7.80 $11.70 $15.60 $15.60 $0.00 2186665 EPSTEIN BARR VIRUS ACCUTE $170.00 86665 302 5/1/2020 zzLRMH_CC_Lab $0.00 $0.00 $85.00 $25.50 $17.00 $25.50 $34.00 $34.00 $0.00 2186765 RUBEOLA IMMUNITY $81.00 86765 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $40.50 $12.15 $8.10 $12.15 $16.20 $16.20 $0.00 2187118 CULTURE MYCOBACTERIAL $134.00 87118 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $67.00 $20.10 $13.40 $20.10 $26.80 $26.80 $0.00 2187206 ACID FAST STAIN $70.00 87206 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $35.00 $10.50 $7.00 $10.50 $14.00 $14.00 $0.00 2187275 INFLUENZE A AG IF $79.00 87275 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 2187276 INFLUENZE B AG IF $79.00 87276 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 2187536 HIV VIRAL LOAD $383.00 87536 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $191.50 $57.45 $38.30 $57.45 $76.60 $76.60 $0.00 2187635 COVID-19 RAPID $200.00 87635 306 2/4/2020 zzLRMH_CC_Lab $0.00 $0.00 $100.00 $30.00 $20.00 $30.00 $40.00 $40.00 $0.00 2196776 VARICELLA ZOSTER AB. IGM $92.00 86787 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $46.00 $13.80 $9.20 $13.80 $18.40 $18.40 $0.00 2198418 HEPATITIS B CORE AB IGG/EGM DI $94.00 86704 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $47.00 $14.10 $9.40 $14.10 $18.80 $18.80 $0.00 2199001 COVID COLLECTION FEE ED $75.00 99001 300 2/4/2020 zzLRMH_CC_Lab $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 21001784 IGA SERUM $89.00 82784 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $44.50 $13.35 $8.90 $13.35 $17.80 $17.80 $0.00 21001834 CD4 $144.00 86361 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $72.00 $21.60 $14.40 $21.60 $28.80 $28.80 $0.00 21058495 MMR MEASLES MUMPS RUBELLA $83.00 86735 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $41.50 $12.45 $8.30 $12.45 $16.60 $16.60 $0.00 21071316 "THC CONFIRMATION, URINE" $50.00 82542 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 21083835 METANEPHRINES $234.00 83835 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $117.00 $35.10 $23.40 $35.10 $46.80 $46.80 $0.00 21084443 THYROID STIMULATING IMMUNOGLOBULIN $324.00 84443 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $162.00 $48.60 $32.40 $48.60 $64.80 $64.80 $0.00 21086677 H PYLORI ANTIBODY $33.00 86677 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $16.50 $4.95 $3.30 $4.95 $6.60 $6.60 $0.00 21123255 CALPROTECTIN - FECAL $300.00 83993 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $150.00 $45.00 $30.00 $45.00 $60.00 $60.00 $0.00 21140104 "TESTOSTERONE, FREE" $147.00 84402 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 21160218 RUBEOLLA ANTIBODIES - IGM $81.00 86765 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $40.50 $12.15 $8.10 $12.15 $16.20 $16.20 $0.00 21164871 CCP IGG ANTIBODIES $99.00 86200 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $49.50 $14.85 $9.90 $14.85 $19.80 $19.80 $0.00 21164947 ANA TITER $100.00 86038 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 21187338 "H. PYLORI STOOL AG, EIA" $110.00 87338 300 11/1/2020 zzLRMH_CC_Lab $0.00 $0.00 $55.00 $16.50 $11.00 $16.50 $22.00 $22.00 $0.00 21280307 THC SCREEN - SERUM $165.00 80307 301 9/1/2020 zzLRMH_CC_Lab $0.00 $0.00 $82.50 $24.75 $16.50 $24.75 $33.00 $33.00 $0.00 21280349 THC - CONFIRMATION $225.00 80349 301 9/1/2020 zzLRMH_CC_Lab $0.00 $0.00 $112.50 $33.75 $22.50 $33.75 $45.00 $45.00 $0.00 21282010 BETA HYDROXYBUTYLRATE $123.00 82010 301 5/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $61.50 $18.45 $12.30 $18.45 $24.60 $24.60 $0.00 21285520 HEPARIN XA $265.00 85520 300 11/1/2020 zzLRMH_CC_Lab $0.00 $0.00 $132.50 $39.75 $26.50 $39.75 $53.00 $53.00 $0.00 21286161 CATECHOLAMINE SERUM $155.00 82384 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $77.50 $23.25 $15.50 $23.25 $31.00 $31.00 $0.00 21286226 DNA ANTIBODY SINGLE STRAND $48.00 86226 302 11/7/2018 zzLRMH_CC_Lab $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 21286708 HEPATITIS A TOTAL AB $40.00 86708 302 12/1/2022 zzLRMH_CC_Lab $0.00 $0.00 $20.00 $6.00 $4.00 $6.00 $8.00 $8.00 $0.00 21287075 CULTURE ANAEROBIC $114.00 87075 309 8/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $57.00 $17.10 $11.40 $17.10 $22.80 $22.80 $0.00 21287081 BETA GROUP A CULTURE $63.00 87081 309 6/1/2021 zzLRMH_CC_Lab $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 21287591 GONORRHEA DNA PROB $62.00 87591 306 11/7/2018 zzLRMH_CC_Lab $0.00 $0.00 $31.00 $9.30 $6.20 $9.30 $12.40 $12.40 $0.00 21287624 PAP IB HPV-HR $350.00 87624 306 11/7/2018 zzLRMH_CC_Lab $0.00 $0.00 $175.00 $52.50 $35.00 $52.50 $70.00 $70.00 $0.00 21287635 COVID-19 SEND-OUT $200.00 U0002 306 3/17/2020 zzLRMH_CC_Lab $0.00 $0.00 $100.00 $30.00 $20.00 $30.00 $40.00 $40.00 $0.00 21287880 STREP A AG $55.00 87880 306 6/1/2021 zzLRMH_CC_Lab $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 21288142 PAP TB BASE REFLEX HPV $111.00 88142 311 11/7/2018 zzLRMH_CC_Lab $0.00 $0.00 $55.50 $16.65 $11.10 $16.65 $22.20 $22.20 $0.00 21334972 ASSAY IGA/IGD/IGG/IGM EACH $87.00 82784 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 21334973 IMMUNOASSAY NONANTIBODY $109.00 83516 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $54.50 $16.35 $10.90 $16.35 $21.80 $21.80 $0.00 21480948 ASSAY OF PSA FREE $62.00 84154 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $31.00 $9.30 $6.20 $9.30 $12.40 $12.40 $0.00 21550400 HEPATITIS C VIRAL LOAD $264.00 87522 306 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $132.00 $39.60 $26.40 $39.60 $52.80 $52.80 $0.00 21716555 NICOTINE AND METABOLITES QUANTITATIVE $120.00 80323 301 10/1/2020 zzLRMH_CC_Lab $0.00 $0.00 $60.00 $18.00 $12.00 $18.00 $24.00 $24.00 $0.00 21716936 LEVETIRACETAM (KEPPRA) $135.00 80177 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $67.50 $20.25 $13.50 $20.25 $27.00 $27.00 $0.00 21716944 LAMOTRIGINE (LAMICTAL) $61.00 80175 301 3/1/2023 zzLRMH_CC_Lab $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 21763910 "BENZODIAZEPINES CONFIRMATION, URINE" $60.00 80346 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $30.00 $9.00 $6.00 $9.00 $12.00 $12.00 $0.00 21799007 DRUG SCREEN W/CONFIRMATION $42.00 80307 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $21.00 $6.30 $4.20 $6.30 $8.40 $8.40 $0.00 21815315 HEPATITIS BE AB $74.00 86707 302 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $37.00 $11.10 $7.40 $11.10 $14.80 $14.80 $0.00 22116766 FECAL REDUCING SUBSTANCE $55.00 84377 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 99990003 LAB MISC CHARGE $1.00 300 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 211287077 MICRO-ORGANISM IDENTIFICATION $25.00 87077 300 1/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 212180159 CLOZAPINE SERUM OR PLASMA $63.00 80159 301 10/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 212180195 SIROLIMUS (SEND OUT) $63.00 80195 301 10/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 212180197 "TACROLIMUS, WHOLE BLOOD" $110.00 80197 301 12/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $55.00 $16.50 $11.00 $16.50 $22.00 $22.00 $0.00 212180307 DRUG ABUSE SCREEN W/ ETOH $108.00 80307 301 12/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $54.00 $16.20 $10.80 $16.20 $21.60 $21.60 $0.00 212182397 ANTI MULLERIAN HORMONE $153.00 82397 301 10/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $76.50 $22.95 $15.30 $22.95 $30.60 $30.60 $0.00 212182657 THIOPURINE METHYLTRANSFERASE $47.00 82657 301 12/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $23.50 $7.05 $4.70 $7.05 $9.40 $9.40 $0.00 212182950 GLUCOSE (2 SPEC) TOLERANCE $81.00 82950 300 5/22/2020 zzLRMH_CC_Lab $0.00 $0.00 $40.50 $12.15 $8.10 $12.15 $16.20 $16.20 $0.00 212182951 GLUCOSE TOLERANCE TEST $93.00 82951 300 5/27/2020 zzLRMH_CC_Lab $0.00 $0.00 $46.50 $13.95 $9.30 $13.95 $18.60 $18.60 $0.00 212182952 GLUCOSE TOLERANCE TEST (ADDITIONAL SAMPLES BEYOND 3) $12.00 82952 301 9/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 212183002 LUTEINIZING HORMONE $44.00 83002 301 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $22.00 $6.60 $4.40 $6.60 $8.80 $8.80 $0.00 212183010 HAPTOGLOBIN QUANT $33.00 83010 300 12/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $16.50 $4.95 $3.30 $4.95 $6.60 $6.60 $0.00 212185660 SICKLE CELL SCREEN $102.00 85660 305 12/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $51.00 $15.30 $10.20 $15.30 $20.40 $20.40 $0.00 212186787 VARICELLA ZOSTER V AB IGG $34.00 86787 302 12/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $17.00 $5.10 $3.40 $5.10 $6.80 $6.80 $0.00 212187502 INFLUENZA A&B $158.00 87502 306 1/27/2019 zzLRMH_CC_Lab $0.00 $0.00 $79.00 $23.70 $15.80 $23.70 $31.60 $31.60 $0.00 212187529 HSV NAA 1+2 $341.00 87529 306 10/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $170.50 $51.15 $34.10 $51.15 $68.20 $68.20 $0.00 212187651 STREP $65.00 87651 306 1/27/2019 zzLRMH_CC_Lab $0.00 $0.00 $32.50 $9.75 $6.50 $9.75 $13.00 $13.00 $0.00 212187801 RSV $130.00 87634 306 1/1/2021 zzLRMH_CC_Lab $0.00 $0.00 $65.00 $19.50 $13.00 $19.50 $26.00 $26.00 $0.00 212284145 PROCALCITONIN $392.00 84145 301 10/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $196.00 $58.80 $39.20 $58.80 $78.40 $78.40 $0.00 212284255 SELENIUM $192.00 84255 301 10/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $96.00 $28.80 $19.20 $28.80 $38.40 $38.40 $0.00 212880307 10 PANEL DRUG SCREEN $350.00 80307 301 6/1/2021 zzLRMH_CC_Lab $0.00 $0.00 $175.00 $52.50 $35.00 $52.50 $70.00 $70.00 $0.00 212881421 PAP IB $44.00 88142 311 11/7/2018 zzLRMH_CC_Lab $0.00 $0.00 $22.00 $6.60 $4.40 $6.60 $8.80 $8.80 $0.00 212886709 HEPATITIS A IGM $38.00 86709 300 9/1/2023 zzLRMH_CC_Lab $0.00 $0.00 $19.00 $5.70 $3.80 $5.70 $7.60 $7.60 $0.00 213284446 VITAMIN E $37.00 84446 300 9/13/2019 zzLRMH_CC_Lab $0.00 $0.00 $18.50 $5.55 $3.70 $5.55 $7.40 $7.40 $0.00 213284590 VITAMIN A $137.00 84590 300 9/13/2019 zzLRMH_CC_Lab $0.00 $0.00 $68.50 $20.55 $13.70 $20.55 $27.40 $27.40 $0.00 215080201 TOPIRAMATE $83.00 80201 301 7/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $41.50 $12.45 $8.30 $12.45 $16.60 $16.60 $0.00 217182436 URINE CHLORIDE $24.00 82436 301 3/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $12.00 $3.60 $2.40 $3.60 $4.80 $4.80 $0.00 217186696 HERPES SIMPLEX VIRUS (HSV) TYPE 1/2 IGM AB $145.00 86694 302 7/1/2019 zzLRMH_CC_Lab $0.00 $0.00 $72.50 $21.75 $14.50 $21.75 $29.00 $29.00 $0.00 218287328 CRYPTOSPORIDIUM $87.00 87328 302 6/1/2022 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 218287337 ENTAMOEBA HISTOLYTICA $87.00 87337 302 6/1/2022 zzLRMH_CC_Lab $0.00 $0.00 $43.50 $13.05 $8.70 $13.05 $17.40 $17.40 $0.00 221676578 ALLERGEN PANEL ZONE 6 $990.00 86003 309 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $495.00 $148.50 $99.00 $148.50 $198.00 $198.00 $0.00 422108144 FECAL FAT RANDOM $74.00 82705 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $37.00 $11.10 $7.40 $11.10 $14.80 $14.80 $0.00 211339/L1001 "IRON, SERUM/VP" $84.00 83540 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $42.00 $12.60 $8.40 $12.60 $16.80 $16.80 $0.00 212014/L1001 FOLIC ACID/ VP $135.00 82746 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $67.50 $20.25 $13.50 $20.25 $27.00 $27.00 $0.00 2180007L1001 CREATININE/VP $72.00 82565 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $36.00 $10.80 $7.20 $10.80 $14.40 $14.40 $0.00 2180016VP AST/VP $76.00 84450 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $38.00 $11.40 $7.60 $11.40 $15.20 $15.20 $0.00 ACRH ACETYLCHOLINE RECEPTOR ANTIBODY - COMPLE "$1,096.00" 83519 301 7/1/2018 zzLRMH_CC_Lab $0.00 $0.00 $548.00 $164.40 $109.60 $164.40 $219.20 $219.20 $0.00 COVIDIGG COVID ANTIBODY IGG $200.00 86769 300 4/28/2020 zzLRMH_CC_Lab $0.00 $0.00 $100.00 $30.00 $20.00 $30.00 $40.00 $40.00 $0.00 L1001 VENIPUNCTURE $20.00 36415 300 2/28/2023 zzLRMH_CC_Lab $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 404154 CAD SCREENING MAMMO $53.00 77052 403 7/1/2018 zzLRMH_CC_Mammography $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 404155 MAMMO SCREENING $327.00 77067 403 7/1/2018 zzLRMH_CC_Mammography $0.00 $0.00 $163.50 $49.05 $32.70 $49.05 $65.40 $65.40 $0.00 404177065 MAMO SCREENING/ $185.00 77065 401 1/1/2019 zzLRMH_CC_Mammography $0.00 $0.00 $92.50 $27.75 $18.50 $27.75 $37.00 $37.00 $0.00 404154K CAD SCREENING KOMEN $1.00 77051 403 7/1/2018 zzLRMH_CC_Mammography $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 4041555K MAMMOGRAM FOR SUSAN KOMEN FOUN $29.00 403 7/1/2018 zzLRMH_CC_Mammography $0.00 $0.00 $14.50 $4.35 $2.90 $4.35 $5.80 $5.80 $0.00 404155K MAMMO KOMEN $25.00 77067 403 7/1/2018 zzLRMH_CC_Mammography $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 301010 ROOM & BOARD $570.00 120 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $285.00 $85.50 $57.00 $85.50 $114.00 $114.00 $0.00 301015 ROOM & BOARD - ISOLATION $850.00 164 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $425.00 $127.50 $85.00 $127.50 $170.00 $170.00 $0.00 3012110 RESPITE ROOM CHG $570.00 120 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $285.00 $85.50 $57.00 $85.50 $114.00 $114.00 $0.00 3241740 D 5W 500 $12.00 540 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 6696360 "IV INFUSION THEREAPY, 1HR FOR HYDRATION" $176.00 96360 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $88.00 $26.40 $17.60 $26.40 $35.20 $35.20 $0.00 6696361 "IV INFUSION HYDRATION, EA ADD HR UP TO 8" $61.00 96361 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 6696365 IV INFUSION THERAPY -1 HR FOR THERAPY $284.00 96365 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $142.00 $42.60 $28.40 $42.60 $56.80 $56.80 $0.00 6696366 "IV INFUSION THERAPY, EA ADD HR UP TO 8" $61.00 96366 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 6696367 "ADDITIONAL SQUENTIAL INFUSION, UP TO 1HR" $88.00 96367 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $44.00 $13.20 $8.80 $13.20 $17.60 $17.60 $0.00 6696368 CONCURRENT INFUSION $88.00 96368 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $44.00 $13.20 $8.80 $13.20 $17.60 $17.60 $0.00 6696374 "IV PUSH, SINGLE OR INTIAL DRUG" $88.00 96374 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $44.00 $13.20 $8.80 $13.20 $17.60 $17.60 $0.00 6696375 EA. ADD'L SEQUENTIAL IV PUSH-NEW DRUG $83.00 96375 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $41.50 $12.45 $8.30 $12.45 $16.60 $16.60 $0.00 6696376 EA ADD'S SEQUENTIAL IV PUSH-SAME DRUG $83.00 96376 260 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $41.50 $12.45 $8.30 $12.45 $16.60 $16.60 $0.00 7736569 INSERT PICC CATH "$1,680.00" 36569 510 7/1/2018 zzLRMH_CC_Med Surg $0.00 $0.00 $840.00 $252.00 $168.00 $252.00 $336.00 $336.00 $0.00 COVIDJ&J1 ADMIN SARS COV2 VAC AD 26.5ML J&J FIRST DOSE $100.00 0031A 771 8/13/2021 zzLRMH_CC_Nursing $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 COVIDMB1 MODERNA COVID-19 VACCINE BIVALENT IM 0.3ML $50.00 0134A 771 9/1/2022 zzLRMH_CC_Nursing $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 COVIDMOD1 COVID MODERNA 1ST ADM SARS COV2 100MC/0.5ML $100.00 0011A 771 8/13/2021 zzLRMH_CC_Nursing $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 COVIDMOD2 COVID MODERNA 2ND ADM SARS COV2 100MC/0.5ML $100.00 0012A 771 8/13/2021 zzLRMH_CC_Nursing $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 COVIDMOD3 COVID MODERNA 3RD ADM SARS COV2 100MC/0.5ML $50.00 0013A 771 8/1/2021 zzLRMH_CC_Nursing $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 COVIDPB1 PFIZER COVID-19 VACCINE BIVALENT IM 0.3ML $50.00 0124A 771 9/1/2022 zzLRMH_CC_Nursing $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 COVIDPFI1 ADM SARS COV2 30MCG/0.3 ML PFIZER 1ST DOSE $100.00 0001A 771 8/13/2021 zzLRMH_CC_Nursing $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 COVIDPFI2 ADM SARS COV2 30MCG/0.3 ML PFIZER 2ND DOSE $100.00 0002A 771 8/13/2021 zzLRMH_CC_Nursing $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 COVIDPFI3 ADM SARS COV2 30MCG/0.3 ML PFIZER 3RD DOSE $50.00 0003A 771 8/1/2021 zzLRMH_CC_Nursing $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 COVIDPFIPED1 PFIZER PEDIATRIC VACCINE BOOSTER DOSE FOR ADMINISTRATION $50.00 0074A 771 5/17/2022 zzLRMH_CC_Nursing $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 COVIDREGENCOVT REGEN-COV TOKEN CHARGE $1.00 M0244 636 8/1/2021 zzLRMH_CC_Nursing $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 COVIDREGENIP REGEN-COV ANTIBODY SUBCUTANEOUS WITH POST ADMIN MONITORING INPATIENT $675.00 M0249 771 8/1/2021 zzLRMH_CC_Nursing $0.00 $0.00 $337.50 $101.25 $67.50 $101.25 $135.00 $135.00 $0.00 COVIDREGENOP REGEN-COV ANTIBODY SUBCUTANEOUS WITH POST ADMIN MONITORING OUTPATIENT $675.00 M0243 771 8/1/2021 zzLRMH_CC_Nursing $0.00 $0.00 $337.50 $101.25 $67.50 $101.25 $135.00 $135.00 $0.00 323135 OBSERVATION ROOM PER HOUR $13.00 G0378 762 7/1/2018 zzLRMH_CC_Observation $0.00 $0.00 $6.50 $1.95 $1.30 $1.95 $2.60 $2.60 $0.00 3230378 "EXTENDED ER AFTER 4HRS, PER HR" $23.00 G0378 762 7/1/2018 zzLRMH_CC_Observation $0.00 $0.00 $11.50 $3.45 $2.30 $3.45 $4.60 $4.60 $0.00 32300378 "EXTENDED ER, AFTER 4 HRS" $23.00 762 7/1/2018 zzLRMH_CC_Observation $0.00 $0.00 $11.50 $3.45 $2.30 $3.45 $4.60 $4.60 $0.00 32310378 "OBSERVATION RM, FIRST HR" $250.00 G0378 762 7/1/2018 zzLRMH_CC_Observation $0.00 $0.00 $125.00 $37.50 $25.00 $37.50 $50.00 $50.00 $0.00 323199219 OBSERVATION MODERATE SEVERITY $250.00 G0378 762 7/1/2018 zzLRMH_CC_Observation $0.00 $0.00 $125.00 $37.50 $25.00 $37.50 $50.00 $50.00 $0.00 40298978 MOBILITY CURRENT STATUS $1.00 G8978 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298979 MOBILITY GOAL STATUS $1.00 G8979 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298980 MOBILITY D/C STATUS $1.00 G8980 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298984 CARRY CURRENT STATUS $1.00 G8984 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298985 CARRY GOAL STATUS $1.00 G8985 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298986 CARRY D/C STATUS $1.00 G8986 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298987 SELF CARE CURRENT STATUS $1.00 G8987 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298988 SELF CARE GOAL STATUS $1.00 G8988 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298989 SELF CARE D/C STATUS $1.00 G8989 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298990 OTHER PT/OT CURRENT STATUS $1.00 G8990 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298991 OTHER PT/OT GOAL STATUS $1.00 G8991 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298993 SUB PT/OT CURRENT STATUS $1.00 G8993 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298994 SUB PT/OT GOAL STATUS $1.00 G8994 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298995 SUB PT/OT D/C STATUS $1.00 G8995 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 402997004 OT RE-EVALUATION $113.00 97004 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 402997010 HOT/COLD MOIST PACK $25.00 97010 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 402997012 MECHANICAL TRACTION PER 15 MINS $63.00 97012 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 402997018 PARAFFIN BATH $26.00 97018 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $13.00 $3.90 $2.60 $3.90 $5.20 $5.20 $0.00 402997022 WHIRLPOOL EXTREMITY $36.00 97022 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 402997026 INFRARED $28.00 97026 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 402997032 ELECTRICAL STIMULATION PER 15 $46.00 97032 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $23.00 $6.90 $4.60 $6.90 $9.20 $9.20 $0.00 402997033 IONTOPHORESIS PER 15 MIN $48.00 97033 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 402997035 ULTRASOUND PER 15 MINS $36.00 97035 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 402997110 THERAPUTIC EXERCISES PER 15 MN $71.00 97110 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $35.50 $10.65 $7.10 $10.65 $14.20 $14.20 $0.00 402997112 NEURO RE-EDUCATION $71.00 97112 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $35.50 $10.65 $7.10 $10.65 $14.20 $14.20 $0.00 402997116 GAIT TRAINING PER 15 MINS. $61.00 97116 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 402997124 MASSAGE $57.00 97124 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $28.50 $8.55 $5.70 $8.55 $11.40 $11.40 $0.00 402997140 MYOFACIAL RELEASE/MANUAL TRACTION $63.00 97140 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 402997165 OT EVAL LOW COMPLEXITY $218.00 97165 434 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $109.00 $32.70 $21.80 $32.70 $43.60 $43.60 $0.00 402997166 OT EVAL MODERATE COMPLEXITY $218.00 97166 434 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $109.00 $32.70 $21.80 $32.70 $43.60 $43.60 $0.00 402997167 OT EVAL HIGH COMPLEXITY $218.00 97167 434 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $109.00 $32.70 $21.80 $32.70 $43.60 $43.60 $0.00 402997168 OT RE-EVALUATION $113.00 97168 434 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 402997504 ORTHOTIC FIT/MEAS/TRAIN PER 15 $75.00 97763 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 402997530 THERAPUTIC ACTIVITIY PER 15 MN $74.00 97530 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $37.00 $11.10 $7.40 $11.10 $14.80 $14.80 $0.00 402997532 COGNITIVE TRAINING PER 15 MIN $79.00 97532 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 402997535 SELF-CARE/HOME MANAGEMENT TRAINING $75.00 97535 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 402997597 WOUND SELECTIVE <20SQ CM $193.00 97597 430 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $96.50 $28.95 $19.30 $28.95 $38.60 $38.60 $0.00 402997602 NON-SELECTIVE WOUND DEBRIDEMENT $128.00 97602 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $64.00 $19.20 $12.80 $19.20 $25.60 $25.60 $0.00 402997750 PHYS PREFORM W/REPORT PER 15MN $79.00 97750 431 7/1/2018 zzLRMH_CC_OT $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 407160 ADRENALIN CHL INJ $20.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407295 IV SC 1/2 20 KCL 1000 $100.00 258 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 1543608 IV ADDITIVE $25.00 71020 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 4071111 OPTIRAY 320 50CC $244.00 Q9967 255 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $122.00 $36.60 $24.40 $36.60 $48.80 $48.80 $0.00 4071112 OPTIRAY 320MG 125CC $486.00 Q9967 255 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $243.00 $72.90 $48.60 $72.90 $97.20 $97.20 $0.00 4071115 FENTANYL 100MCG INJ $20.00 J3010 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 4071194 CLONIDINE 0.3MG/24HR PATCH $194.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $97.00 $29.10 $19.40 $29.10 $38.80 $38.80 $0.00 4071205 PEPTO BISMOL TAB $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 4071300 NORPINEPHRINE BITARTRATE 4MG/4ML INJ $50.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 4071777 VALSARTIN 80MG TAB $4.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.00 $0.60 $0.40 $0.60 $0.80 $0.80 $0.00 4071808 TERAZOSIN TAB 10MG $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 4071850 BABY ASPIREN CHEWABLE 89MG TAB $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 4071895 MOTRIN 800 MG $2.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 4071950 HYDROXYZIME LIQUID PER 5ML $2.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 4072990 D 10 W INJ 1000 CC $79.00 258 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 32503073 IV D5 W 500 $68.00 258 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 32511610 EAR TRAY $10.00 250 12/1/2020 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 40710001 ROCEPHIN 250MG $24.00 J0696 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.00 $3.60 $2.40 $3.60 $4.80 $4.80 $0.00 40710004 "PENICILLING BENZATHINE &PENICILLIN G PROCAINE 100,000 UNITS" $20.00 J0558 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 40710005 "PENICILLIN G BENZATHINE, 100,000 UNITS" $35.00 J0561 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 40710007 DIVALPROEX 250MG DR $13.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.50 $1.95 $1.30 $1.95 $2.60 $2.60 $0.00 40710091 TRIPLE ANTIBIOTIC OINT 30GM $8.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 40710130 "EFFER-K 25 MEQ TABLET EFF 25 mEq, 30 eaches" $7.00 259 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 40711160 BACITRACIN OINT U/D $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 40711460 BETADINE SOL. 4 OZ $23.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $11.50 $3.45 $2.30 $3.45 $4.60 $4.60 $0.00 40711696 PNEUMOCOCCAL INJ ADMINISTRATIO $27.00 G0009 771 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $13.50 $4.05 $2.70 $4.05 $5.40 $5.40 $0.00 40712020 CAPTOPRIL TAB 25MG $5.00 259 1/1/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 40712030 CAPOTEN 12.5 MG $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 40712640 ANTI ITCH CREAM $20.00 259 1/26/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 40713232 PREDNISOLONE 1% OPTH SOL $26.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $13.00 $3.90 $2.60 $3.90 $5.20 $5.20 $0.00 40713680 BIAXIN 500MG $18.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $9.00 $2.70 $1.80 $2.70 $3.60 $3.60 $0.00 40713810 DEMEROL 100MG/CC INJ $20.00 J2175 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 40714390 DILANTIN SUSP 5CC PO $3.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 40715630 FLU VACCINE 1/2CC INJ $21.00 90658 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 40715640 FLU VACCINE ADMINISTRATION FEE $30.00 G0008 771 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 40715940 GARAMYCIN 80MG PREMIX $50.00 J1580 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 40716019 LAMISIL CR 1% 30 GM $26.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $13.00 $3.90 $2.60 $3.90 $5.20 $5.20 $0.00 40716190 GLYCERIN CHILD SUPP $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 40716320 HALOPERIDAL 5MG INJECTION $20.00 J1630 636 3/21/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 40716521 HEPATITIS ADMINISTRATION FEE $28.00 G0010 771 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 40716610 HYDROCORTISONE CR 1% 30GM $10.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 40717130 ISMO 20MG $3.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 40717855 LANOXIN .25MG TAB $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40717970 "LIDOCAINE OINT 5% 1,25GM" $53.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 40718165 LOTRISONE CR 15GM $115.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $57.50 $17.25 $11.50 $17.25 $23.00 $23.00 $0.00 40718260 MACRODANTIN 50MG $3.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 40718390 MANNITOL 50ML INJ $20.00 J2150 636 4/1/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 40718510 CEFOXITIN INJ 1GM $20.00 J0694 636 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 40718680 METAMUCIL POWDER DRAM $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40718905 MEGACE ORAL SUSP 10CC $25.00 S0179 250 12/1/2020 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 40719060 "ROCEPHIN 1GM, PER 250MG PREMIX" $120.00 J0696 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $60.00 $18.00 $12.00 $18.00 $24.00 $24.00 $0.00 40719110 MYLANTA LIQ 5 OZ $19.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 40719120 MYLANTA 30CC $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 40719402 "NICODERM CQ 21 MG/24HR PATCH, EACH" $6.00 259 9/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 40720093 10% DEXTROSE IN WATER 500ML $78.00 258 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $39.00 $11.70 $7.80 $11.70 $15.60 $15.60 $0.00 40725900 IV ADDITIVE $25.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 47150508 GUAIFENESIN DM SYRUP 100mg-10MG PER 5ML 0-5ML $6.00 259 1/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 71043087 LUNESTA 3MG $12.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 407100014 MINOXIDIL TAB 2.5MG $2.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407100016 NUBAIN 20MG INJ $20.00 J2300 636 4/1/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407100017 DIVALPROEX TAB ER 500MG $9.00 259 4/1/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.50 $1.35 $0.90 $1.35 $1.80 $1.80 $0.00 407100018 RISPERIDAL 1MG TAB $14.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.00 $2.10 $1.40 $2.10 $2.80 $2.80 $0.00 407100020 IMITREX 25MG TABLET $68.00 259 3/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 407100035 CO-ENZYME 200MG CAP $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407100037 VANCOMYCIN 750MG INJ $150.00 J3370 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $75.00 $22.50 $15.00 $22.50 $30.00 $30.00 $0.00 407100044 AMOXICILLIN 200MG/5ML $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407100045 BUPROPION 150MG SR $15.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407100047 VESICARE TAB 5MG $33.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $16.50 $4.95 $3.30 $4.95 $6.60 $6.60 $0.00 407100061 "PREGABALIN 75 MG CAPSULE, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407100064 "BICILLIN LA PER 100,000 UNITS" $266.00 J0561 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $133.00 $39.90 $26.60 $39.90 $53.20 $53.20 $0.00 407100065 TEFLARO 600MG INJ $527.00 J0712 636 4/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $263.50 $79.05 $52.70 $79.05 $105.40 $105.40 $0.00 407100070 BUTRANS TD [ 5MCG/HR ] $93.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $46.50 $13.95 $9.30 $13.95 $18.60 $18.60 $0.00 407100100 "VANCOMYCIN ORAL SOLUTION, 50MG/ML" $153.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $76.50 $22.95 $15.30 $22.95 $30.60 $30.60 $0.00 407100101 "ASPRIN 325MG TABLET, EACH" $6.00 259 11/11/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407100102 "SILVER NITRATE APPLICATOR, 1 EACH" $7.00 250 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407100105 CALMOSEPTINE OINTMENT PACKET 3.5GM UD $6.00 259 9/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407100106 RANEXA 500MG TABLET $12.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 407100110 "Protonix IV 40 MG VIAL, EACH" $20.00 250 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407100111 "ETHYL CHLORIDE SPRAY MEDIUM SPRAY, 103.5ML" $45.00 259 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $22.50 $6.75 $4.50 $6.75 $9.00 $9.00 $0.00 407100115 BUTRANS PATCH [ 10MG ] $137.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $68.50 $20.55 $13.70 $20.55 $27.40 $27.40 $0.00 407100116 "CHLORHEXIDINE GLUCONATE 0.12% ORAL RINSE, 0-15ML" $7.00 259 12/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407100117 TPN $600.00 B4189 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $300.00 $90.00 $60.00 $90.00 $120.00 $120.00 $0.00 407100201 PREVNAR 13 VACCINE $180.00 90670 636 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $90.00 $27.00 $18.00 $27.00 $36.00 $36.00 $0.00 407100211 INVOKANA 100MG TABLET $29.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $14.50 $4.35 $2.90 $4.35 $5.80 $5.80 $0.00 407100300 DEPLIN CP 15MG $11.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 407100367 "REVONTO 20 MG VIAL, EACH" $100.00 250 11/25/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 407100401 "CALCIUM CARBONATE 500MG CHEW TABLET, EACH" $6.00 259 11/7/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407100411 "morphine 2 MG/ML SYRINGE 1 ea, 1 mL" $10.00 J2270 636 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407100450 ANCEF 1GM ADVANTAGE VIAL $20.00 J0690 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407100500 THEOPHYLLINE ER TAB 400MG $5.00 259 12/1/2016 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407100511 "morphine 4 MG/ML SYRINGE 1 ea, 1 mL" $10.00 J2270 636 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407100512 "FLORAJEN 3 CAPSULE, EACH" $6.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407100532 GI COCKTAIL COMPOUNDED SUSPENSION 0-60ML $7.00 259 11/5/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407100604 "SPS 30GM/120ML ENEMA SUSP, EACH" $155.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $77.50 $23.25 $15.50 $23.25 $31.00 $31.00 $0.00 407100611 "DESITIN 40% PASTE 1 ea, 28 g" $6.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407100630 "AMPICILLIN-SULBACTAM 3 GM VIAL, EACH" $15.00 J0295 636 11/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407100635 "NASAL DECONGESTANT 0.05% SPRAY 1 ea, 15 mL" $6.00 259 8/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407100660 "SPS 15 GM/60 ML SUSPENSION 1 ea, 60 mL" $35.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 407100700 ZOFRAN SOLUTION 4MG/5ML $13.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.50 $1.95 $1.30 $1.95 $2.60 $2.60 $0.00 407100701 PROLIA 60MG INJ "$3,649.00" J0897 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 "$1,824.50" $547.35 $364.90 $547.35 $729.80 $729.80 $0.00 407100702 "DOPamine 400MG IN D5W 250ML IV SOLUTION, 1 BAG" $20.00 J1265 636 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407100710 "ROCURONIUM 50 MG/5 ML VIAL, EACH" $10.00 250 2/27/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407100801 BIAXIN 500MG TABLET $19.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 407100811 BENAZEPRIL TAB 5MG $3.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407100816 "NYSTATIN 100,000 UNITS/ML SUSPENSION 0-5ML" $7.00 259 1/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407100819 PEDIACTRIC ATROPINE $35.00 J0461 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 407100832 "Mucinex ER 600 MG TABLET, EACH" $6.00 259 11/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407100834 "Mucinex ER 600 MG TABLET, EACH" $6.00 259 11/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407100861 "LORazepam 1 MG TABLET, EACH" $10.00 259 2/8/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407100890 DOBUTAMINE 250MG INJ $20.00 J1250 636 3/24/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407100901 MAGNESIUM SULFATE 10ML SYRINGE $50.00 J3475 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 407100911 "Dilaudid 1 MG/ML SYRINGE 1 ea, 1 mL" $10.00 J1170 636 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407100920 FIRST MOUTHWASH $117.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $58.50 $17.55 $11.70 $17.55 $23.40 $23.40 $0.00 407100930 LANSOPRAZOLE KIT $200.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $100.00 $30.00 $20.00 $30.00 $40.00 $40.00 $0.00 407100940 LIDOCAINE/PRILOCAINE 2.5/2.5 (EMLA CREAM) $20.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407100950 NYSTATIN OINTMENT 15GM $43.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 407101030 "SANTYL OINTMENT 0.1 GRAM, EACH" $15.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407101094 "gentamicin 80 MG/2 ML VIAL 1 ea, 2 mL" $10.00 J1580 636 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407101101 "HYOSCYAMINE 0.125 MG TABLET SL, EACH" $7.00 259 3/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407101104 "CHLORASEPTIC SORE THROAT SPRAY 1 g, 177 mL" $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407101106 "CHLORASEPTIC SORE THROAT LOZENGE, EACH" $6.00 259 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407101155 "ALBUTEROL SUL 1.25 MG/3 ML SOL 1 ea, 3 mL" $7.00 J7613 636 6/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407101201 "CYCLOBENZAPRINE 5MG TABLET, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407101259 "ALLERGY (CHLORPHENIRAMINE) 4MG TABLET, EACH" $6.00 259 10/23/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407101269 "MAGNESIUM OXIDE 250 MG TABLET, 1 each" $6.00 259 1/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407101280 "ALLERGY 4 MG TABLET, EACH" $6.00 259 11/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407101310 "Lovenox 30 MG/0.3 ML SYRINGE, EACH" $10.00 J1650 636 10/26/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407101410 "Lovenox 40 MG/0.4 ML SYRINGE, EACH" $10.00 J1650 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407101490 "PREGABALIN 100 MG CAPSULE, EACH" $10.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407101501 "AMOXICILLIN 875 MG TABLET, EACH" $7.00 259 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407101600 GENTAMYCIN OPTH OINT 0.3% $50.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 407101601 PROPARACAINE 0.5% EYE DROPS 0.1 mL (0-2 DROPS) $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407101604 "BUMETANIDE 1 MG TABLET, EACH" $7.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407101610 "Lovenox 60 MG/0.6 ML SYRINGE, EACH" $10.00 J1650 636 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407101700 "CALCIUM 600 MG-VIT D3 10MCG TABLET, EACH" $6.00 259 4/29/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407101702 "DEXTROSE 5%-WATER IV SOLN 250 mL, 1 BAG" $10.00 258 11/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407101703 "DEXTROSE 5% WATER IV SOLUTION 500 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407101704 "DEXTROSE 5% WATER IV SOLUTION 1000 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407101760 "DULoxetine HCL DR 20 MG CAPSULE, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407101810 "Lovenox 80 MG/0.8 ML SYRINGE, EACH" $10.00 J1650 636 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407101930 DULoxetine HCL DR 60 MG CAPSULE $7.00 259 6/18/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407102000 MIDAZOLAM LIQ [5MG/2.5ML] $18.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $9.00 $2.70 $1.80 $2.70 $3.60 $3.60 $0.00 407102010 "Lovenox 100 MG/ML SYRINGE, EACH" $14.00 J1650 636 10/26/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.00 $2.10 $1.40 $2.10 $2.80 $2.80 $0.00 407102106 "MIRTAZAPINE 15 MG ODT TABLET, EACH" $7.00 259 2/27/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407102182 "VANCOMYCIN 1 GM VIAL, EACH" $10.00 J3370 636 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407102230 "AZITHROMYCIN 250 MG TABLET, EACH" $7.00 259 10/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407102303 "DEXTROSE 10% WATER IV SOLUTION 500 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407102350 "HYDROcodone-Acetaminophen 7.5mg-325mg per 15ml UD, EACH" $10.00 259 4/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407102367 "BACITRACIN ZN 500 UNIT/GM OINT, EACH" $6.00 259 4/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407102402 "COMBIVENT RESPIMAT 20-100 MCG 1 ea, 4 g" $620.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $310.00 $93.00 $62.00 $93.00 $124.00 $124.00 $0.00 407102404 "METAMUCIL FIBER SINGLES PACKET 3.4GM, EACH" $6.00 259 8/21/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407102439 "ERYTHROMYCIN 0.5% EYE OINTMENT 1 ea, 3.5 g" $18.00 259 8/21/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $9.00 $2.70 $1.80 $2.70 $3.60 $3.60 $0.00 407102515 "LIDOCAINE ANORECTAL 5% CREAM 1 ea, 15 g" $25.00 259 9/15/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407102721 "oxyBUTYnin 5 MG TABLET 1 ea, 100 eaches" $7.00 259 4/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407102819 VECURONIUM 10MG INJ $28.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 407103023 "FOILLE OINTMENT 30GM TUBE, EACH" $6.00 259 11/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407103125 "TOBRAMYCIN-DEXAMETH OPHTH SUSP 1 ea, 2.5 mL" $30.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407103134 "MIRTAZAPINE 15 MG TABLET, EACH" $7.00 259 2/27/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407103200 "VITAMIN B-12 500 MCG TABLET, EACH" $6.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407103315 "BETAMETHASONE VALER 0.1% OINTM 15GM, EACH" $15.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407103401 "antacid 500 MG CHEW TABLET, EACH" $6.00 259 11/11/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407103402 "DAPTOmycin 500 MG VIAL 500 mg, 1 each" $30.00 J0878 636 3/17/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407103815 "AMITRIPTYLINE HCL 25 MG TABLET, EACH" $7.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407103915 "AMITRIPTYLINE HCL 50 MG TABLET, EACH" $7.00 259 10/27/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407103928 "SOLU-MedroL 40MG/ML VIAL, EACH" $40.00 J2930 636 8/10/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $20.00 $6.00 $4.00 $6.00 $8.00 $8.00 $0.00 407104103 "VANCOMYCIN 500 MG/100 ML BAG 1 ea, 100 mL" $20.00 J3370 636 9/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407104161 "ALLOPURINOL 100MG TABLET, EACH" $7.00 259 5/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407104164 "CATHFLO ACTIVASE 2 MG VIAL, EACH" $260.00 J2997 636 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $130.00 $39.00 $26.00 $39.00 $52.00 $52.00 $0.00 407104203 "VANCOMYCIN 1 GRAM/200 ML BAG, EACH" $25.00 J3370 636 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407104302 "VANCOMYCIN 1.5 GRAM/300 ML BAG, EACH" $31.00 J3370 636 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.50 $4.65 $3.10 $4.65 $6.20 $6.20 $0.00 407104304 "SODIUM CHLORIDE 0.45% SOLN 1000 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407104401 "CYANOCOBALAMIN 1,000 MCG/ML VL 1 ea, 1 mL" $10.00 J3420 636 3/5/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407104702 "NITROGLYCERIN 25MG IN D5W 250ML IV SOLUTION, 1 BOTTLE" $20.00 J3490 636 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407104704 "SOLU-MedroL 125 MG VIAL, EACH" $12.00 J2930 636 10/24/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 407104761 "LOSARTAN POTASSIUM 25 MG TABLET, EACH" $7.00 259 11/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407104824 "levoFLOXacin 750 MG/150 ML-D5W 750 mg, 150 mL" $10.00 J1956 636 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407104902 "TRIAMCINOLONE ACET 40 MG/ML VL 40 mg pe, 1 mL" $10.00 J3301 636 10/14/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407104903 "SODIUM CHLORIDE 0.9% IV SOLUTION 500ML, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407104904 "SODIUM CHLORIDE 0.9% IV SOLUTION 1000 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407104905 "TRIAMCINOLONE ACET 40 MG/ML VL 1 ea, 1 mL" $10.00 J3301 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407104918 "SODIUM CHLORIDE 0.9% SOLUTION 100 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407104931 "SODIUM CHLORIDE 0.9% IV SOLUTION 50 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407104961 "LOSARTAN POTASSIUM 100 MG TABLET, EACH" $7.00 259 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407105001 "metOLazone 2.5 MG TABLET, EACH" $7.00 259 2/19/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407105004 FIRST-MOUTHWASH BLM (MAGIC MOUTHWASH) COMPOUNDING KIT 0-5ML $7.00 259 1/13/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407105012 "BISACODYL 10 MG SUPPOSITORY, EACH" $6.00 259 11/25/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407105301 "DAPTOmycin 350 MG VIAL, EACH" $20.00 J0878 636 7/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407105403 "SODIUM CHLORIDE 3% IV SOLN 1 ea, 500 mL" $20.00 258 7/15/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407105501 "metOLazone 5 MG TABLET 5 mg, EACH" $7.00 259 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407105603 "VANCOMYCIN 750 MG/150 ML BAG, EACH" $20.00 J3370 636 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407105612 "ACETAMINOPHEN-COD #4 TABLET, EACG" $10.00 259 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407105634 "Mucinex DM ER 600-30 MG TABLET, EACH" $6.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407105702 "VANCOMYCIN 1.25 GM/250 ML BAG, EACH" $30.00 J3370 636 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407105761 "methocarbamoL 500 MG TABLET, EACH" $7.00 259 10/23/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407105861 "methocarbamoL 750 MG TABLET, EACH" $7.00 259 11/4/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407105910 MIDAZOLAM HCL 1MG PER ML INJECTION 0-1ML $10.00 J2250 636 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407105911 "nystatin 100,000 UNIT/GM CREAM 1 ea, 30 g" $10.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407105935 "NYSTATIN TOPICAL CREAM 15GM, EACH" $10.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407106070 BACITRACIN 500 UNIT/GM OINTMNT 0.9GM UD $6.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407106115 "ACYCLOVIR 400 MG TABLET, EACH" $7.00 259 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407106205 "SUCRALFATE 1 GM/10 ML SUSP 100 mg pe, 420 mL" $7.00 250 10/10/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407106215 "ACYCLOVIR 800 MG TABLET, EACH" $7.00 259 2/2/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407106301 "metFORMIN HCL 500 MG TABLET, EACH" $7.00 259 11/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407106403 "MAGNESIUM SULFATE 50% VIAL 2ML, EACH" $10.00 J3475 636 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407106412 "H-CHLOR 12 0.125% SOLUTION 473ML, EACH" $17.00 250 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $8.50 $2.55 $1.70 $2.55 $3.40 $3.40 $0.00 407106424 "heparin 500 UNIT/5 ML (100/ML) 500 unit, 5 mL" $10.00 J1642 636 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407106443 "MAGNESIUM SULFATE 50% VIAL 1 GRAM, 2 mL" $10.00 J3475 636 12/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407107301 "BUTALB-ACETAMIN-CAF-COD 50-325-40-30MG CAPSULE, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407107401 "ASCOMP WITH CODEINE CAPSULE, EACH" $10.00 259 4/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407107420 "hydrALAZINE 10 MG TABLET, EACH" $7.00 259 1/25/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407107924 "FLEET GLYCERIN 2 GM ADULT SUPP, EACH" $6.00 259 8/7/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407108002 "fentaNYL 12 MCG/HR PATCH, EACH" $35.00 259 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 407108005 FIRST-LANSOPRAZOLE 3MG/ML ORAL SUSPENSION COMPOUNDING KIT 150ML $133.00 259 2/5/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $66.50 $19.95 $13.30 $19.95 $26.60 $26.60 $0.00 407108031 "HYDROCORTISONE 2.5% CREAM 1 ea, 30 g" $4.00 259 4/14/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.00 $0.60 $0.40 $0.60 $0.80 $0.80 $0.00 407108112 "FLEET PEDIA-LAX SUPPOSITORY, EACH" $6.00 259 8/7/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407108261 "zolpidem TARTRATE 5 MG TABLET, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407108305 "SODIUM BICARBONATE 4.2% VIAL 5ML, EACH" $20.00 250 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407108361 "CIPROFLOXACIN HCL 500 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407108404 "buPROPion HCL XL 150 MG TABLET, EACH" $7.00 259 11/25/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407108411 "TAZICEF 2 GRAM VIAL, EACH" $20.00 J0713 636 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407108504 "DEXTROSE 5%-0.45% NACL IV SOLUTION 1000 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407108527 "Activase 100 MG VIAL 100 mg, 1 each" "$14,000.00" J2997 636 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 "$7,000.00" "$2,100.00" "$1,400.00" "$2,100.00" "$2,800.00" "$2,800.00" $0.00 407108561 "CITALOPRAM HBR 20 MG TABLET, EACH" $7.00 259 10/24/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407108717 "ATROVENT 17 MCG HFA INHALER, EACH" $650.00 259 11/11/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $325.00 $97.50 $65.00 $97.50 $130.00 $130.00 $0.00 407108815 "ARIPiprazole 5 MG TABLET, EACH" $7.00 259 11/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407108904 "DEXTROSE 5%-0.9% NS IV SOLUTION 1000 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407109915 "KETOCONAZOLE 2% CREAM 1 ea, 15 g" $12.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 407110001 IPRATROPIUM BROMIDE 0.02% INH SOL 2.5ML UD $10.00 J7644 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407110018 RISPERDAL 1MG $14.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.00 $2.10 $1.40 $2.10 $2.80 $2.80 $0.00 407110102 "SODIUM CHLORIDE 0.9% ADD-VANTAGE IV BAG 250 mL, 250 mL" $10.00 258 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407110122 DURAGESIC PATCH 75MG $154.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $77.00 $23.10 $15.40 $23.10 $30.80 $30.80 $0.00 407110167 "SODIUM CHLORIDE 0.9% 100ml ADV BAG, EACH" $20.00 258 4/29/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407110212 "ALBUTEROL SULF 2 MG/5 ML SYRUP, 0-10ML" $7.00 259 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407110301 "SWABFLUSH 0.9% NACL SYRINGE 10 mL, EACH" $10.00 250 1/1/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407110310 "EPINEPHrine 1MG/ML AMPUL, EACH" $20.00 J0171 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407110380 NEOSPORIN OPTH OINT 3.5GM $88.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $44.00 $13.20 $8.80 $13.20 $17.60 $17.60 $0.00 407110401 "VITAMIN D3 1,000 UNIT TABLET, EACH" $6.00 259 11/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407110421 "ketorolac 10 MG TABLET, EACH" $8.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 407110427 "ECOTRIN EC 81 MG TABLET, EACH" $6.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407110601 "DIVALPROEX DR 125 MG CAP SPRINKLE, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407110616 "MYLANTA ORAL SUSPENSION 0-30ML, EACH" $6.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407110730 "rOPINIRole HCL ER 2 MG TABLET, EACH" $7.00 259 9/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407110788 "NICOTINE 14 MG/24HR PATCH, EACH" $7.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407110801 "MAGNESIUM SULF 1 G/100 ML-D5W 1 ea, 100 mL" $10.00 J3475 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407110803 "TRANEXAMIC ACID IN 0.7% NACL 10 MG/ML IN 100 ML PREMIXED BAG, EACH" $20.00 250 6/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407110953 "AMOXICILLIN 500 MG CAPSULE, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407110961 "labetalol HCL 100 MG TABLET, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407111015 "benazepril HCL 10 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407111101 "K-PHOS ORIGINAL 500MG TABLET, EACH" $7.00 259 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407111115 "benazepril HCL 20 MG TABLET, EACH" $7.00 259 5/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407111281 FELODIPINE TAB 5MG $3.00 250 4/1/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407111293 "NITROGLYCERIN 0.4 MG/HR PATCH, EACH" $7.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407111301 "cloNIDine HCL 0.1 MG TABLET, EACH" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407111310 "Ketalar 200 MG/20 ML VIAL 10 mg/ml, 20 mL" $30.00 250 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407111383 CYMBALTA 30MG $18.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $9.00 $2.70 $1.80 $2.70 $3.60 $3.60 $0.00 407111402 "FEVERALL 80 MG SUPPOSITORY, EACH" $6.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407111502 "FEVERALL 120MG CHILDRENS SUPPOSITORY, EACH" $6.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407111510 "PHENAZOPYRIDINE 200 MG TABLET, EACH" $7.00 259 11/7/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407111551 PPD SKIN TEST REPEAT $20.00 86580 250 8/1/2019 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407111580 PREDNISONE 5MG $1.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407111602 "FEVERALL 325 MG SUPPOSITORY 325 mg, EACH" $6.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407111610 "AMPICILLIN-SULBACTAM 1.5 GM VL 1 ea, 1 each" $10.00 J0295 636 11/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407111704 "LACTATED RINGERS IV SOLUTION 1000 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407111780 SILTUSSIN SA 100 MG/5 ML LIQUID 0-20ML $6.00 259 10/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407111861 "metoprolol tartrate 50 MG TABLET, EACH" $7.00 259 4/29/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407111925 "ketorolac 60 MG/2 ML VIAL, EACH" $10.00 J1885 636 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407112000 ROBITUSSIN DM 5-10CC $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407112047 "TNKase 50 MG KIT, EACH" "$11,180.00" J3101 636 9/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 "$5,590.00" "$1,677.00" "$1,118.00" "$1,677.00" "$2,236.00" "$2,236.00" $0.00 407112150 "PIPERACIL-TAZOBACT 4.5 GM VIAL, EACH" $10.00 J2543 636 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407112161 "busPIRone HCL 10 MG TABLET, EACH" $7.00 259 10/27/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407112261 "busPIRone HCL 5 MG TABLET, EACH" $7.00 259 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407112361 "levETIRAcetam 250 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407112365 "FluZONE HIGH-DOSE QUAD 2023-24 1 ea, 0.7 mL" $175.00 90662 636 8/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $87.50 $26.25 $17.50 $26.25 $35.00 $35.00 $0.00 407112462 "HYDROcodone-acetamin 7.5-325MG TABLET, EACH" $10.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407112480 GUAIFENESIN LIQ 100MG/5ML $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407112561 "levETIRAcetam 750 MG TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407112562 "HYDROcodone-acetamin 10-325 MG tablet, 1 each" $10.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407112576 "fentaNYL 25 MCG/HR PATCH, EACH" $20.00 259 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407112612 "MYXREDLIN 100 UNIT/100 ML BAG 100 mL, EACH" $31.00 J1815 636 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.50 $4.65 $3.10 $4.65 $6.20 $6.20 $0.00 407112761 "predniSONE 20 MG TABLET, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407112838 "ADULTS 50 PLUS MULTIVITAMIN, EACH" $6.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407112959 "LOPERAMIDE 2 MG/15 ML ORAL SOL 2 mg, 15 mL" $5.35 259 10/14/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.68 $0.80 $0.54 $0.80 $1.07 $1.07 $0.00 407113011 "DOXYCYCLINE 100MG VIAL, EACH" $20.00 250 4/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407113112 COREG 25 $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407113125 "SILVADENE 1% CREAM 25GM TUBE, EACH" $10.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407113210 SOLUCORTEF UP TO 100MG INJ $40.00 J1720 636 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $20.00 $6.00 $4.00 $6.00 $8.00 $8.00 $0.00 407113230 "SOLU-CORTEF 500MG INJ, UP TO 100MG" $125.00 J1720 636 3/24/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $62.50 $18.75 $12.50 $18.75 $25.00 $25.00 $0.00 407113260 SOLU-MEDROL 500MG INJ $63.00 J2930 636 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 407113501 MIRAPEX 0.5 $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407113515 "busPIRone HCL 15 MG TABLET, EACH" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407113634 "diazePAM 10 MG/2 ML SYRINGE, EACH" $30.00 J3360 636 10/27/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407113701 "BENZTROPINE MES 1 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407113705 "LIDOCAINE HCL 1% SYRINGE, EACH" $20.00 J2001 636 12/9/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407113800 TALWIN TAB $7.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407113914 "TOPIRAMATE 50 MG TABLET 1 ea, 60 eaches" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407113917 "MELATONIN 10 MG TABLET, EACH" $6.00 259 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407114004 "Zyvox 600 MG/300 ML-D5W PREMIXED BAG, EACH" $20.00 J2020 636 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407114044 CATAPRES TTS-3 PATCH $107.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $53.50 $16.05 $10.70 $16.05 $21.40 $21.40 $0.00 407114100 "glipiZIDE 5 MG TABLET, EACH" $7.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407114120 "chlordiazePOXIDE 25 MG CAPSULE, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407114170 TETANUS TOXOID INJ $125.00 90703 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $62.50 $18.75 $12.50 $18.75 $25.00 $25.00 $0.00 407114171 TET DIPTHERIA VACC $100.00 90714 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 407114309 HYDROCORTISONE CREAM 2.5% 30GM $36.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 407114342 ERYTHROMYCIN OPTH OINT $53.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 407114380 THORAZINE UP TO 50MG INJ $90.00 J3230 636 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $45.00 $13.50 $9.00 $13.50 $18.00 $18.00 $0.00 407114411 "AZITHROMYCIN 500 MG ADD-VAN VL 500 mg, 1 each" $20.00 J0456 636 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407114461 "droNABinol 2.5 MG CAPSULE, EACH" $10.00 259 8/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407114601 "hydroCHLOROthiazide 12.5 MG CAPSULE, EACH" $7.00 259 10/19/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407114610 "ETOMIDATE 20 MG/10 ML VIAL 2 mg pe, 10 mL" $10.00 250 10/13/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407114704 "CEFEPIME HCL 2 GRAM VIAL, EACH" $20.00 J0692 636 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407114809 VITAMIN C 1000MG TABLET $6.00 259 9/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407115001 ITRACONAZOLE 10 MG/ML SOLUTION 0-20ML $33.00 250 10/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $16.50 $4.95 $3.30 $4.95 $6.60 $6.60 $0.00 407115050 URISPAS $3.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407115076 "fentaNYL 50 MCG/HR PATCH, EACH" $30.00 259 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407115120 "VITAMIN D 50,000 UNITS (1.25MG) CAPSULE" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407115160 VALIUM 10MG INJ $27.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $13.50 $4.05 $2.70 $4.05 $5.40 $5.40 $0.00 407115202 POTASSIUM PHOSPHATE INJ $48.00 250 1/23/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 407115203 SODIUM PHOSPHATE INJ $20.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407115207 CALCIUM CHLORIDE INJECTION $20.00 J0620 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407115209 MORPHINE LIQUID $2.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407115213 ZANTAC 25MG INJ $36.00 J2780 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 407115214 DICLOFENAC TAB 75MG $5.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407115215 "CEPHALEXEIN 500MG CAPSULE, EACH" $7.00 259 11/7/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407115440 "LACTULOSE 20 GM/30 ML SOLUTION 1 ea, 30 mL" $7.00 259 10/14/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407115455 NEURONTIN 300 $5.00 250 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407115504 "OXYBUTYNIN CL ER 5 MG TABLET, EACH" $7.00 259 5/13/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407115604 "PIPERACIL-TAZOBACT 2.25 GM VIAL, EACH" $20.00 J2543 636 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407115676 PRIMAL DEFENSE $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407115700 "VITAMIN B COMPLEX-VITAMIN C TABLET, EACH" $6.00 259 11/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407115704 "PIPERACIL-TAZOBACT 3.375 GM VIAL, EACH" $20.00 J2543 636 11/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407115713 "ONDANSETRON ODT 4 MG TABLET, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407115910 VISTARIL 25MG CAP $3.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407116101 KETOROLAC 15MG/ML 1ML VIAL $7.00 J1885 636 11/25/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407116160 LEVOPHED 4MG/4ML INJ $55.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 407116202 MORPHINE 2MG CARPUJECT $20.00 J2270 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407116205 "LIDOCAINE HCL 1% 50 MG/5 ML VL 1 ea, 5 mL" $10.00 250 9/29/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407116216 "ketorolac 30 MG/ML VIAL 1 ea, 1 mL" $10.00 J1885 636 10/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407116242 NORMODYNE 200 MG TAB $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407116261 "metFORMIN HCL 500 MG TABLET, EACH" $7.00 259 2/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407116315 "chlorproMAZINE 25 MG TABLET 1 ea, 50 eaches" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407116320 CHLORASEPTIC SPRAY $7.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407116333 MAGIC MOUTHWASH $22.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $11.00 $3.30 $2.20 $3.30 $4.40 $4.40 $0.00 407116461 "metFORMIN HCL 1,000 MG TABLET, EACH" $7.00 259 9/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407116516 "dexAMETHasone 4 MG/ML VIAL, EACH" $10.00 J1100 636 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407116715 "CHLORTHALIDONE 25 MG TABLET, EACH" $7.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407116840 "PENICILLIN 5 MILLION UNITS, PER 600,000 UNITS" $70.00 J2540 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $35.00 $10.50 $7.00 $10.50 $14.00 $14.00 $0.00 407116870 PROMETHAZINE/CODEINE ELIXER PER 5ML $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407116889 ADRENALIN 30 MG/30 ML INJECTION 0-0.1MG $10.00 J0171 636 2/2/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407116892 SALINE FLUSH SYRINGES $16.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $8.00 $2.40 $1.60 $2.40 $3.20 $3.20 $0.00 407116958 "ENALAPRILAT 2.5 MG/2 ML VIAL 1 ea, 2 mL" $15.00 250 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407116969 PNEUMOCOCCAL INJECTION $175.00 90732 636 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $87.50 $26.25 $17.50 $26.25 $35.00 $35.00 $0.00 407117027 "LIDOCAINE HCL 1% 50 MG/5 ML VL 1 ea, 5 mL" $10.00 250 11/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407117101 "AMITRIPTYLINE HCL 10 MG TABLET, EACH" $7.00 259 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407117123 NEOSTIGMINE METHYLSULFATE 0.5MG/ML INJECTION 0-1ML $10.00 J2710 636 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407117167 "BENADRYL ITCH STOPPING CRM 28.3 GM, EACH" $5.35 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.68 $0.80 $0.54 $0.80 $1.07 $1.07 $0.00 407117270 EES 400MG TAB $25.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407117272 VERAPAMIL 5MG/2ML $50.00 J3490 636 3/24/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 407117300 LIDOCAINE JELLY 5ML $20.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407117301 "SUMAtriptan 6 MG/0.5 ML VIAL 1 ea, 0.5 mL" $10.00 J3030 636 1/1/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407117312 GAVISCON EXTRA STRENGTH LIQUID 0.20ML $6.00 259 4/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407117322 XYLOCAINE 1%/EPI UP TO 10MG INJ $20.00 J2001 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407117355 ALBUTEROL 1MG U/D DME $8.00 J7610 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 407117401 "buPROPion HCL SR 100 MG TABLET, EACH" $7.00 259 11/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407117430 CITROMAG 10 OZ $4.00 250 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.00 $0.60 $0.40 $0.60 $0.80 $0.80 $0.00 407117501 "VENLAFAXINE HCL 75 MG TABLET, EACH" $7.00 259 10/20/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407117601 "penicillin VK 500 MG TABLET, EACH" $7.00 259 5/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407117630 "DEMEROL 25 MG/ML CARPUJECT 1 ea, 1 mL" $10.00 J2175 636 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407117761 "FUROSEMIDE 20 MG TABLET, EACH" $7.00 259 2/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407117780 PONTOCAINE OPTH SOL. $90.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $45.00 $13.50 $9.00 $13.50 $18.00 $18.00 $0.00 407117803 "TUMS EX 750MG CHEWABLE TABLET, EACH" $6.00 259 5/13/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407117830 "DEMEROL 50 MG/ML CARPUJECT 50 mg pe, 1 mL" $10.00 J2175 636 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407117856 PROMETHAZINE-CODEINE SOLUTION $1.05 250 10/14/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.53 $0.16 $0.11 $0.16 $0.21 $0.21 $0.00 407117861 "FUROSEMIDE 40 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407117880 NIPRIDE INJ 5 ML $95.00 J3490 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $47.50 $14.25 $9.50 $14.25 $19.00 $19.00 $0.00 407117925 "dexAMETHasone 0.5 MG TABLET, each" $7.00 259 1/15/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407117940 LIDOCAINE 2% 20MG/ML IVP $20.00 J2001 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407117961 "traMADoL HCL 50 MG TABLET, EACH" $10.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407117970 NITROGLYCERIN ER 2.5MG $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407118120 "KETAMINE 200 MG/20 ML VIAL 200 mg, 20 mL" $30.00 250 4/14/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407118170 ALUPENT PER DOSE $8.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 407118210 "ORPHENADRINE 60 MG/2 ML VIAL 1 ea, 2 mL" $10.00 J2360 636 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407118311 "MEROPENEM-0.9% NACL 500 MG/50ML, EACH" $30.00 J2185 636 12/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407118325 "dexAMETHasone 6 MG TABLET, EACH" $7.00 259 2/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407118361 "DOCUSATE SODIUM 100 MG SOFTGEL, EACH" $6.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407118510 "WATER FOR INJECTION VIAL 1 ea, 10 mL" $10.00 250 12/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407118610 "0.9% SODIUM CHLORIDE INJECTION 10ML VIAL, EACH" $10.00 250 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407118640 LIDEX CR 15 GM $100.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 407118761 "PHENYTOIN SOD EXT 100 MG CAPSULE, EACH" $7.00 259 12/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407118915 "CYPROHEPTADINE 4 MG TABLET, EACH" $7.00 259 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407118960 NAVANE 5MG CAP $3.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407119115 "CYCLOBENZAPRINE 10 MG TABLET, EACH" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407119260 "FEXOFENADINE HCL 60 MG TABLET, EACH" $6.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407119315 "cloNIDine HCL 0.2 MG TABLET, EACH" $7.00 259 11/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407119401 "NIFEdipine 10 MG CAPSULE, EACH" $7.00 259 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407119461 "clindamycin HCL 300 MG CAPSULE, EACH" $7.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407119640 SODIUM BICARB TAB $1.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407119820 TRANSDERMSCOP $55.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 407120001 "PREVNAR 20 SYRINGE 0.5 mL, 0.5 mL" $241.00 90671 636 3/8/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $120.50 $36.15 $24.10 $36.15 $48.20 $48.20 $0.00 407120030 "ALBUTEROL SULFATE 0.083% (2.5MG/3ML) INH SOL, EACH" $10.00 J7613 636 4/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407120061 "LISINOPRIL 40 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407120102 "LIDOCAINE HCL 1% VIAL 10MG/2ML SDV, EACH" $10.00 250 2/2/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407120104 EMETROL ORAL SOLUTION 0-30ML $6.00 259 8/21/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407120326 "VANCOMYCIN HCL 750 MG VIAL, EACH" $10.00 J3370 636 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407120350 PEPCID 20MG TAB $6.00 250 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407120401 "METOCLOPRAMIDE 5 MG TABLET, EACH" $7.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407120605 FIRVANQ 50 MG/ML SOLUTION 150ML $200.00 259 8/1/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $100.00 $30.00 $20.00 $30.00 $40.00 $40.00 $0.00 407120725 "LORazepam 2 MG/ML VIAL, EACH" $10.00 J2060 636 2/5/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407120806 "NIFEdipine ER 30 MG TABLET, EACH" $7.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407120820 "EPOGEN/PROCRIT 40,000 UNITS" $600.00 J0885 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $300.00 $90.00 $60.00 $90.00 $120.00 $120.00 $0.00 407120825 "PROMETHAZINE 25 MG/ML VIAL, EACH" $10.00 J2550 636 11/25/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407120870 ROBITUSSIN AC [100/10MG PER 5ML] $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407120995 "cefTRIAXone 2 GM VIAL, EACH" $10.00 J0696 636 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407121101 "Jantoven 1 MG TABLET, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407121201 "Jantoven 2 MG TABLET, EACH" $7.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407121202 "ASPIRIN EC 81 MG TABLET, EACH" $6.00 259 4/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407121211 "midodrine HCL 5 MG TABLET, EACH" $7.00 259 11/19/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407121501 "Jantoven 4 MG TABLET, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407121584 TOBRAMYCIN INJ 80MG $20.00 J3260 636 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407121601 "Jantoven 5 MG TABLET, EACH" $7.00 259 7/15/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407121761 "dilTIAZem 24H ER(CD) 120 MG CP 1 ea, 100 eaches" $7.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407122033 Lantus U-100 INSULIN 0-5 UNITS $10.00 259 9/1/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407122044 SENEKOT $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407122045 NAPHCON A OPTH $41.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $20.50 $6.15 $4.10 $6.15 $8.20 $8.20 $0.00 407122101 "carBAMazepine 200 MG TABLET, EACH" $7.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407122110 "ERTAPENEM 1 GRAM VIAL 1 g, 1 each" $40.00 J1335 636 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $20.00 $6.00 $4.00 $6.00 $8.00 $8.00 $0.00 407122189 ISOSORBIDE MONO TAB 60MG $5.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407122296 ADALET CC 90MG $8.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 407122320 ROBAFEN DM 200-20 MG/20 ML LIQUID 0-20ML $6.00 259 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407122416 "ALENDRONATE SODIUM 70 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407122461 "folic acid 1 MG TABLET, EACH" $7.00 259 11/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407122515 "DESENEX 2% POWDER 1 ea, 43 g" $6.00 259 9/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407122761 "clonazePAM 0.5 MG TABLET, EACH" $10.00 259 7/15/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407122901 "LOPERAMIDE 2 MG CAPSULE, EACH" $6.00 259 10/22/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407123042 ARIMIDEX 1MG $28.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 407123301 "BETAMETHASONE DP 0.05% CRM 15GM, EACH" $30.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407123423 QUETIAPINE 25MG TAB $10.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407123525 "cefTAZidime 1 GM VIAL, EACH" $20.00 J0713 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407123661 "megestroL 40 MG TABLET, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407124041 "METOCLOPRAMIDE 10 MG/2 ML VIAL 1 ea, 2 mL" $10.00 J2765 250 8/1/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407124161 "haloperidoL 1 MG TABLET, EACH" $7.00 259 2/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407124304 "ceFAZolin 1 GM VIAL, EACH" $20.00 J0690 636 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407124404 DEXFERRON INJ $160.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $80.00 $24.00 $16.00 $24.00 $32.00 $32.00 $0.00 407124409 GASTROVIEW 500ML DILUTED $226.00 A9698 255 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $113.00 $33.90 $22.60 $33.90 $45.20 $45.20 $0.00 407124504 "CEFEPIME HCL 1 GM VIAL, EACH" $20.00 J0692 636 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407124792 "BENZOIN TINCTURE 1 ea, 59 mL" $16.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $8.00 $2.40 $1.60 $2.40 $3.20 $3.20 $0.00 407124908 RALOXIFENE TAB 60MG $20.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407125115 "TRIAMCINOLONE 0.1% CREAM 15 g, 15 g" $7.00 259 4/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407125601 "PROPAFENONE HCL 150 MG TABLET, EACH" $7.00 259 4/24/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407125761 "CARBIDOPA-LEVODOPA 25-100 TABLET, EACH" $7.00 259 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407125790 PRIMIDONE TAB 50MG $2.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407125815 "CLOTRIMAZOLE-BETAMETHASONE 1-0.05% CREAM, 15GM" $10.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407125915 "DIVALPROEX SOD ER 250 MG TABLET, EACH" $7.00 259 2/2/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407125930 "ACETYLCYSTEINE 6 GRAM/30 ML VL 1 ea, 30 mL" $50.00 J0132 636 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 407126110 "DICYCLOMINE 10 MG/5 ML ORAL SOLUTION, 0-5ML" $7.00 259 10/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407126195 "AMPICILLIN 1 GM VIAL, EACH" $10.00 J0290 636 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407126501 "metoprolol tartrate 25 MG TABLET, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407126510 "levETIRAcetam-NaCl 1,000MG/100 1000 mg, 100 mL" $30.00 J1953 636 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407126593 "levETIRAcetam 500 MG/5 ML CUP 1 ea, 5 mL" $7.00 259 2/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407126661 "dexAMETHasone 4 MG TABLET, EACH" $7.00 259 2/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407126754 "labetalol HCL 200 MG/40 ML VL 5 mg pe, 40 mL" $15.00 250 4/3/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407126808 "MIRALAX POWDER PACKET 17GM, EACH" $6.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407126910 "ROPINIROLE 0.5MG TABLET, EACH" $7.00 259 4/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407126994 "Diprivan 200 MG/20 ML VIAL 200 mg, 20 mL" $10.00 J2704 636 4/24/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407127110 "rOPINIRole HCL 2 MG TABLET, EACH" $7.00 259 10/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407127434 "AMOX-CLAV 500-125 MG TABLET, EACH" $7.00 259 11/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407127520 "GAS-X EXTRA STRENGTH SOFTGEL, EACH" $6.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407127534 "AMOX-CLAV 875-125 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407127601 "LIDOCAINE HCL 1% VIAL 10 mg pe, 20 mL" $10.00 J2001 636 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407127603 "HYDROCORTISONE 1% OINTMENT 28GM, EACH" $6.00 259 5/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407127692 "nystatin 500,000 UNIT/5 ML CUP 1 ea, 5 mL" $7.00 259 4/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407127746 "VITAMIN E 450 MG SOFTGEL, EACH" $6.00 259 3/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407127840 RACEPHINIC EPINEPHRINE PER DOSE $3.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407128004 "FUROSEMIDE 40 MG/4 ML VIAL 1 ea, 4 mL" $10.00 J1940 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407128016 "FUROSEMIDE 20 MG/2 ML VIAL, EACH" $10.00 J1940 636 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407128319 PREDNISONE ORAL PER 5MG $2.00 J7506 250 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407128420 "diazePAM 2 MG TABLET, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407128426 "VANCOMYCIN 1 GM VIAL, EACH" $10.00 J3370 636 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407128435 "GENTAK 0.3 % EYE OINTMENT 3.5GM, 1 TUBE" $48.00 259 11/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 407128520 "diazePAM 5 MG TABLET, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407128636 STOMACH RLF 525 MG/30 ML SUSP 0-30ML $6.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407128773 PRIMAXIN 250MG INJ $43.00 J0743 636 3/24/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 407129006 "ATORVASTATIN 10 MG TABLET, EACH" $7.00 259 11/7/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407129161 "ATORVASTATIN 20MG TABLET, EACH" $7.00 259 12/22/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407129206 "atorvastatin 40 MG TABLET, EACH" $7.00 259 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407129301 "VERAPAMIL ER 180 MG TABLET, EACH" $7.00 259 11/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407129361 "POTASSIUM CL ER 20 MEQ TABLET, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407129461 "CLOPIDOGREL 75 MG TABLET, EACH" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407129496 SOD CHLORIDE TAB 1GM $1.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407129685 "ALBUTEROL HFA 90 MCG INHALER 1 ea, 6.7 g" $30.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407129716 LODINE 500MG $4.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.00 $0.60 $0.40 $0.60 $0.80 $0.80 $0.00 407129738 ACIDOPHILUS TAB $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407129901 "tamsulosin HCL 0.4 MG CAPSULE, EACH" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407130003 "SODIUM CHLORIDE 0.9% INHAL VL 3 mL, 3 mL" $7.00 259 6/12/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407130024 "CIPROFLOXACIN 400 MG/200ML-D5W, EACH" $20.00 J0744 636 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407130061 "carvediloL 3.125 MG TABLET, EACH" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407130133 "SODIUM CHLORIDE 0.9% INH SOL 3ML, EACH" $10.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407130161 "carvediloL 6.25 MG TABLET, EACH" $7.00 259 4/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407130261 "carvediloL 12.5 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407130301 "NITROFURANTOIN MONO-MCR 100 MG CAPSULE, EACH" $7.00 259 11/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407130403 "NITROGLYCERIN 0.4 MG TABLET SL, EACH" $7.00 259 11/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407130575 DIAZEPAM 5MG/5ML SOL $6.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407130608 "SIMETHICONE 180 MG SOFTGEL, EACH" $6.00 259 5/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407130661 "diphenhydrAMINE 25 MG CAPSULE 25 mg, 100 eaches" $6.00 259 5/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407131002 ESTRADIOL .5MG TAB $1.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407131005 "VENOFER 200 MG/10 ML VIAL 200 mg, 10 mL" $97.00 J1756 636 11/2/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $48.50 $14.55 $9.70 $14.55 $19.40 $19.40 $0.00 407131200 "MUPIROCIN 2% OINTMENT 22GM, EACH" $7.00 250 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407131228 "PROCTO-MED HC 2.5% CREAM 28GM, EACH" $12.00 250 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 407131230 "HYDROmorphone 2 MG/ML CARPUJECT, EACH" $10.00 J1170 636 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407131275 DIPRIVAN 100MG/10ML $2.00 J2704 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407131291 SALINE NASAL SPRAY $10.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407131306 "ROCEPHIN 2GM VIAL, PER 250MG" $314.00 J0696 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $157.00 $47.10 $31.40 $47.10 $62.80 $62.80 $0.00 407131415 "FINASTERIDE 5 MG TABLET, EACH" $7.00 259 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407131675 AMBIEN 10 $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407131801 "dilTIAZem 30 MG TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407131840 "ORAJEL 3X MEDICATED GEL 5.1GM, EACH" $10.00 250 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407131906 "buPROPion HCL XL 150 MG TABLET, EACH" $7.00 259 11/26/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407132001 "labetalol HCL 100 MG/20 ML VL 100 mg, 20 mL" $10.00 J1920 636 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407132006 "buPROPion HCL XL 300 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407132010 "labetalol HCL 20 MG/4 ML VIAL 1 ea, 4 mL" $10.00 250 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407132206 "metoprolol SUCCinate ER 25 MG TABLET, EACH" $7.00 259 11/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407132501 "LISINOPRIL 10 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407132510 "ACYCLOVIR 500 MG/10 ML VIAL, EACH" $10.00 J0133 636 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407132608 "NITRO-BID 2% OINTMENT 1GM, EACH UD" $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407132630 "NITRO-BID 2% OINTMENT 30GM, EACH" $53.00 250 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 407132675 CIPROFLOX-DEXAMETH OTIC SUSP 0-4 DROPS (0.14ML) $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407132862 REFRESH EYE GEL $3.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407133015 "FLUDROCORTISONE 0.1 MG TABLET, EACH" $7.00 259 7/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407133260 FOLIC ACID 1MG INJ $17.00 J3490 636 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $8.50 $2.55 $1.70 $2.55 $3.40 $3.40 $0.00 407133701 "cefTRIAXone 250 MG VIAL 250 mg, 1 each" $20.00 J0696 636 2/8/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407133706 "ACETAMINOPHEN-CODEINE 120-12 MG/5ML UD cup, 5ML" $10.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407133801 "cefTRIAXone 500 MG VIAL 500 mg, 1 each" $20.00 J0696 636 10/14/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407133950 "VANCOMYCIN 500 MG VIAL, each" $20.00 J3370 636 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407134001 "ATROPINE 1 MG/10 ML SYRINGE 1 mg, 10 mL" $65.00 J0461 636 8/10/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $32.50 $9.75 $6.50 $9.75 $13.00 $13.00 $0.00 407134567 "DONNATOL ELIXER, PER 5ML" $95.00 259 1/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $47.50 $14.25 $9.50 $14.25 $19.00 $19.00 $0.00 407134701 "LOSARTAN POTASSIUM 50 MG TABLET, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407135015 "GEMFIBROZIL 600 MG TABLET, EACH" $7.00 259 2/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407135201 "SODIUM BICARB 8.4% SYRINGE 50 mL, EACH" $25.00 250 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407135261 "levoFLOXacin 500 MG TABLET, EACH" $7.00 259 11/7/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407135361 "levoFLOXacin 750 MG TABLET, EACH" $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407135412 KAYEXALATE 15GM/60ML $30.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407136015 "GLIMEPIRIDE 4 MG TABLET, EACH" $7.00 259 1/15/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407136019 "CALCIUM GLUC 1,000 MG/10 ML VIAL, EACH" $16.00 J0612 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $8.00 $2.40 $1.60 $2.40 $3.20 $3.20 $0.00 407136020 "NEXTERONE 360 MG/200 ML BAG, EACH" $72.00 J0282 636 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $36.00 $10.80 $7.20 $10.80 $14.40 $14.40 $0.00 407136961 "amLODIPine BESYLATE 2.5 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407137061 "amLODIPine BESYLATE 5 MG TABLET, EACH" $7.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407137161 "amLODIPine BESYLATE 10 MG TABLET, EACH" $7.00 259 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407137520 "chlordiazePOXIDE 10 MG CAPSULE, EACH" $10.00 259 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407137557 "VENOFER 100MG, PER 1MG INJ" $300.00 J1756 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $150.00 $45.00 $30.00 $45.00 $60.00 $60.00 $0.00 407137761 "OLANZapine 5 MG TABLET, EACH" $7.00 259 5/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407137801 "VITAMIN B COMPLEX SOFTGEL, EACH" $6.00 259 8/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407138057 NITROGLYCERN 0.1MG PATCH $5.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407138080 "AYR SALINE 0.65% NOSE SPRAY 1 ea, 50 mL" $6.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407138630 "SOLIFENACIN 5 MG TABLET, EACH" $7.00 259 8/21/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407138701 "TUSSIN DM 400-20 MG/20 ML LIQUID, 0-20ML" $6.00 259 9/29/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407138914 "AZITHROMYCIN IV 500 MG VIAL, EACH" $10.00 J0456 636 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407139001 "LIDOCAINE HCL 2% (100mg/5ml) LUER-JET SYRINGE, EACH" $15.00 J2001 636 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407139110 "ONDANSETRON ODT 8 MG TABLET, EACH" $7.00 259 2/19/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407140020 "Adacel TDAP SYRINGE 1 ea, 0.5 mL" $75.00 90715 636 1/25/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 407140044 "levETIRAcetam 500 MG/5 ML VIAL, EACH" $10.00 250 8/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407140230 "FLUoxetine HCL 10 MG TABLET, EACH" $7.00 259 12/8/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407140440 VERAPAMIL SR 120MG $3.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407140761 "BISACODYL EC 5 MG TABLET, EACH" $6.00 259 10/14/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407140811 ZIPRASIDONE 20MG CAP $23.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $11.50 $3.45 $2.30 $3.45 $4.60 $4.60 $0.00 407140885 cefUROXime SOD 1.5 GM VIAL PER 750MG $20.00 J0697 636 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407141001 "A&d DIAPER RASH CREAM 42.5GM, EACH" $6.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407141024 "CLINDAMYCIN 300 MG/50 ML-D5W 1 ea, 50 mL" $10.00 S0077 636 2/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407141035 "DIGOXIN 500 MCG/2 ML AMPULE, EACH" $10.00 J1160 636 1/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407141210 "MEROPENEM IV 1 GM VIAL, EACH" $20.00 J2185 636 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407141272 ATROVENT UNIT DOSE $8.00 J7644 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 407141273 DEXAMETHASONE INH SOL PER MG $20.00 J7638 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407141292 "CALCIUM CARBONATE (ANTACID) 500 MG CHEW TAB, EACH" $6.00 259 11/26/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407142107 "CELECOXIB 200 MG CAPSULE, EACH" $7.00 259 10/24/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407142296 "heparin SOD 5,000 UNIT/ML VIAL 1 ea, 1 mL" $10.00 J1644 636 1/25/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407142316 DOCUSATE SODIUM 50 MG/5 ML LIQUID 0-10ML $6.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407142350 "FluZONE QUAD 2023-2024 SYRINGE 1 ea, 0.5 mL" $52.00 90688 636 8/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $26.00 $7.80 $5.20 $7.80 $10.40 $10.40 $0.00 407142405 "FLUMAZENIL 0.1 MG/ML VIAL 5 mL, EACH" $10.00 250 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407142510 "dilTIAZem 25 MG/5 ML VIAL, EACH" $10.00 250 8/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407142661 "escitalopram 10 MG TABLET, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407142761 "ESCITALOPRAM 20 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407142793 VALSARTIN 160MG TAB $9.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.50 $1.35 $0.90 $1.35 $1.80 $1.80 $0.00 407142804 "DOXYCYCLINE HYCLATE 100 MG CAPSULE, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407143015 "INDOMETHACIN 25 MG CAPSULE, EACH" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407143294 DURAGESIC 100MG PATCH $225.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $112.50 $33.75 $22.50 $33.75 $45.00 $45.00 $0.00 407143464 "NP THYROID 60 MG TABLET 60 mcg, 100 eaches" $7.00 250 2/26/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407143624 "levoFLOXacin 500 MG/100 ML-D5W 1 ea, 100 mL" $30.00 J1956 636 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407144161 "hydrALAZINE 25 MG TABLET, EACH" $7.00 259 7/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407144184 SYNTHROID TAB 137MCG $5.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407144261 "hydrALAZINE 50 MG TABLET, EACH" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407144593 SYNTHROID TAB 175MCG $2.00 250 4/1/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407144633 SYNTHROID 150 MCQ TAB $2.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407144670 "NICOTINE 7 MG/24HR PATCH, EACH" $6.00 259 4/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407144769 SYNTHROID TAB 25MCG $5.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407144801 MINERAL OIL 0-30ML $5.35 250 10/10/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.68 $0.80 $0.54 $0.80 $1.07 $1.07 $0.00 407144861 "PENTOXIFYLLINE ER 400 MG TABLET, EACH" $7.00 259 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407144915 "ISOSORBIDE DINITRATE 20 MG TABLET, EACH" $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407144926 DIASTAT GEL 2.5MG $465.00 250 4/1/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $232.50 $69.75 $46.50 $69.75 $93.00 $93.00 $0.00 407144932 SYNTHROID 112MCG $5.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407144961 "ISOSORBIDE MONONIT ER 30 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407145805 "FENOFIBRATE 145 MG TABLET 145 mg, 90 eaches" $7.00 259 12/4/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407145811 "TYLENOL 325MG CAPLET, EACH" $6.00 259 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407145909 FIBER LAXATIVE 625MG TABLET $6.00 259 5/13/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407146092 "OYSTER SHELL 500-VIT D3 200 TABLET, EACH" $6.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407146161 "PROMETHAZINE 25 MG TABLET, EACH" $7.00 259 5/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407146377 SYSTANE OPTH DROPS $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407146515 "NYAMYC 100,000 UNIT/GM POWDER 1 ea, 15 g" $8.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 407146530 "OCUVITE ADULT 50 PLUS SOFTGEL, EACH" $6.00 259 1/23/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407146560 "NYAMYC TOPICAL POWDER 60GM, EACH" $25.00 259 2/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407146617 "SENSORCAINE-MPF 0.5% VIAL 1 ea, 10 mL" $10.00 250 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407146807 "lovastatin 20 MG TABLET, EACH" $7.00 259 11/4/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407147201 "INFANT PAIN-FEVER 160 MG/5 ML DROPS, 0-5ML" $6.00 259 6/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407147220 CORTEF 10MG TAB $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407147380 LIDOCAINE 5% OINTMENT 50GM $20.00 259 9/15/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407147401 CHILD ALLERGY RELIEF (DIPHENHYDRAMINE) 12.5 MG/5 ML 0-10ML $6.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407147501 "RAMIPRIL 2.5 MG CAPSULE, EACH" $7.00 259 11/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407147561 "BACLOFEN 10 MG TABLET, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407147701 "RAMIPRIL 10 MG CAPSULE, EACH" $7.00 259 4/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407147715 "LEFLUNOMIDE 10 MG TABLET, EACH" $7.00 259 8/7/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407147761 "DONEPEZIL HCL 5 MG TABLET, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407148227 "XYLOCAINE 1%-EPI 1:100,000 10 mg, 1ML" $10.00 250 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407148327 "XYLOCAINE 2%-EPI 1:100,000 20MG, 1ML" $10.00 250 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407148462 "ACETAMINOPHEN-COD #3 TABLET, EACH" $10.00 259 7/15/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407148501 "hydrOXYchloroQUINE 200 MG TABLET, EACH" $7.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407148601 "TRIMETHOPRIM 100 MG TABLET, EACH" $7.00 259 4/16/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407148610 "hydrOXYzine HCL 25 MG TABLET, EACH" $7.00 259 7/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407148626 "XYLOCAINE 2% INJECTION 20MG, 1ML" $10.00 250 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407148717 "XYLOCAINE-MPF 1%-EPI 1:200,000 VIAL 10ML, EACH" $10.00 250 2/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407148901 DESMOPRESSIN ACETATE 0.1 MG TABLET $7.00 259 10/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407148986 VITAMIN B- 12 500MCG TABLET $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407149101 "NAPROXEN 500 MG TABLET, EACH" $7.00 259 5/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407149227 "XYLOCAINE-MPF 1% VIAL 20 mg, 2 mL" $10.00 J2001 636 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407149236 "XYLOCAINE-MPF 1% VIAL 50 mg, 5 mL" $10.00 J2001 636 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407149261 "THERA M PLUS TABLET, EACH" $6.00 259 4/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407149325 "PHENYTOIN 50 MG/ML VIAL 2ML, EACH" $7.00 J1165 636 10/14/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407149462 "CHILDREN IBUPROFEN 100 MG/5 ML UD CUP, EACH" $6.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407150001 "hydrOXYzine HCL 10 MG TABLET, EACH" $7.00 259 6/12/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407150002 "THIAMINE 200MG/2ML VIAL, EACH" $10.00 J3411 636 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407150006 "FLUCONAZOLE 100 MG TABLET, EACH" $7.00 259 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407150049 LIDOCAINE 2% VISCOUS SOLN 0-5ML $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407150111 "NovoLOG 100 UNIT/ML INSULIN, 0-5 UNITS" $7.00 J1815 259 1/15/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407150160 "ALBUTEROL SUL 2.5 MG/3 ML INH SOLN 1 ea, 3 mL" $10.00 J7613 636 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407150404 ACETAMINOP-CODEINE 120-12 MG/5 ML LIQUID 0-5ML $10.00 259 4/20/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407150415 "LOSARTAN POTASSIUM 25 MG TABLET, EACH" $7.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407150504 "SCOPOLAMINE 1 MG/3 DAY PATCH, EACH" $15.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407150606 "MEMANTINE HCL 10 MG TABLET, EACH" $7.00 259 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407150616 "dexAMETHasone 10 MG/ML VIAL 1ML, EACH" $10.00 J1100 636 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407150720 "MEROPENEM IV 500 MG VIAL 500 mg, 1 each" $20.00 J2185 636 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407151001 HumaLOG 100 UNIT/ML INSULIN 0-5 UNITS $7.00 J1815 259 1/15/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407151034 CELECOXIB CAPS 100MG {CELEBREX] $13.00 250 12/4/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.50 $1.95 $1.30 $1.95 $2.60 $2.60 $0.00 407151761 "MECLIZINE 25 MG TABLET, EACH" $7.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407151766 "DEXTROSE 50% (25GM/50ML) SYRINGE, EACH" $20.00 250 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407151805 "TOBRAMYCIN 0.3% OPHTHALMIC SOLUTION 5ML, EACH" $12.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 407151991 OXCARBAZEPINE 600MG TAB $13.00 259 9/7/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.50 $1.95 $1.30 $1.95 $2.60 $2.60 $0.00 407152010 "MELATONIN 5 MG TABLET, EACH" $6.00 259 5/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407152076 "ACTIDOSE 50 GM LIQUID, 240ML" $30.00 259 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407152083 "PFIZERPEN 5 MILLION UNIT VIAL, 1 EACH" $20.00 J2540 636 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407152301 "URINARY PAIN RELIEF 99.5 MG TABLET, EACH" $6.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407152341 "PROCHLORPERAZINE 10 MG/2 ML VIAL, EACH" $10.00 J0780 636 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407152361 "VITAMIN C 500 MG TABLET, EACH" $6.00 259 11/9/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407152515 "MELOXICAM 7.5 MG TABLET, EACH" $7.00 259 6/18/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407152530 LIDOCAINE 5% TOPICAL PATCH $10.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407152612 "PROMETHEGAN 25 MG SUPPOSITORY, EACH" $7.00 259 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407152615 "MELOXICAM 15 MG TABLET, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407152715 "metHOTREXate 2.5 MG TABLET, EACH" $7.00 259 4/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407152725 "lithium carbonate 300 MG CAPSULE, EACH" $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407152730 "VENLAFAXINE HCL ER 37.5 MG CAPSULE, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407152830 "VENLAFAXINE HCL ER 75 MG CAP 1 ea, 30 eaches" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407152960 "CHOLESTYRAMINE LIGHT POWDER PACKET 4GM, EACH" $7.00 259 4/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407153004 "EYE-STREAM SOLUTION 1 ea, 118 mL" $50.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 407153401 "VANCOMYCIN 500 MG ADD-VAN VIAL, EACH" $10.00 J3370 636 10/27/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407153429 KETOCONAZOLE 2% CREAM 15GM $128.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $64.00 $19.20 $12.80 $19.20 $25.60 $25.60 $0.00 407153501 "VANCOMYCIN 1 GM ADD-VAN VIAL 1 g, 1 each" $10.00 J3370 636 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407153515 "metroNIDAZOLE 500 MG TABLET, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407153612 "PROMETHEGAN 12.5 MG SUPPOSITORY, EACH" $7.00 259 5/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407153924 DIAZEPAM RECTAL GEL 10MG $285.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $142.50 $42.75 $28.50 $42.75 $57.00 $57.00 $0.00 407154115 "metoprolol succ ER 50 MG TABLET, EACH" $7.00 259 11/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407154124 "metroNIDAZOLE 500 MG/100 ML 500 mg, 100 mL" $20.00 S0030 636 10/27/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407154258 POTASSIUM CHLORIDE 10% (20MEQ/15ML) ORAL SOLUTION 0-15ML $7.00 259 12/4/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407154842 "ONDANSETRON HCL 4 MG/2 ML VIAL, EACH" $10.00 J2405 636 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407154976 "MAXIPIME 1GM ,PER 500MG ADV" $20.00 J0692 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407155000 "guaiFENesin WITH CODEINE 200mg-20mg per 10ml UD cup, EACH" $10.00 259 12/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407155003 COUMADIN 10MG TAB $3.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407155006 "PROMETHAZINE 50 MG/ML 1ML AMPULE, EACH" $10.00 J2550 636 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407155015 "metFORMIN HCL ER 500 MG TABLET, EACH" $7.00 259 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407155061 "PROPRANOLOL 10 MG TABLET, EACH" $7.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407155161 "ONDANSETRON HCL 4 MG TABLET, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407155304 "LINEZOLID 600 MG TABLET, EACH" $7.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407155318 "SODIUM CHLORIDE 0.9% MINI BAG PLUS IV SOLUTION 100 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407155501 "clonazePAM 1 MG TABLET, EACH" $10.00 259 11/4/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407155619 "CALTRATE 600+D PLUS TABLET, EACH" $6.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407155761 "morphine SULF ER 15 MG TABLET, EACH" $10.00 259 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407156016 "AZACTAM 1 GM VIAL, EACH" $45.00 S0073 636 12/9/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $22.50 $6.75 $4.50 $6.75 $9.00 $9.00 $0.00 407156115 "midodrine HCL 2.5 MG TABLET, EACH" $7.00 259 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407156312 LEXAPRO 20 $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407156629 SINEMET TAB 23/100MG TAB $2.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407156787 2% LIDOCAINE W EPINEPHRINE 20M $25.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407157004 "BUMETANIDE 1 MG/4 ML VIAL 1 ea, 4 mL" $10.00 S0171 636 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407157210 "simvastatin 20 MG TABLET, EACH" $7.00 259 10/24/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407157261 "ALLOPURINOL 300 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407157305 "methylPREDNISolone 40 MG/ML VL 1 ea, 1 mL" $12.00 J1030 636 1/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $6.00 $1.80 $1.20 $1.80 $2.40 $2.40 $0.00 407157310 "simvastatin 40 MG TABLET 1 ea, 100 eaches" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407157458 "VITAMIN A 10,000 IU" $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407157504 "HIBICLENS 4% LIQUID 1 ea, 118 mL" $7.00 259 5/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407157830 "XARELTO 15 MG TABLET, EACH" $21.00 259 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 407157901 "HYDROmorphone 2 MG TABLET, EACH" $10.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407157930 "XARELTO 20 MG TABLET, EACH" $21.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 407158030 "XARELTO 10 MG TABLET, EACH" $21.00 259 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.50 $3.15 $2.10 $3.15 $4.20 $4.20 $0.00 407158121 "PRAMIPEXOLE 0.5 MG TABLET, EACH" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407158379 ALLEGRA 180MG TAB $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407158381 "C Q 10 TAB, 200MG" $1.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407158501 "ceFAZolin 1 GM ADD-VAN VIAL 1 g, 1 each" $20.00 J0690 636 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407158792 NASONEX NASAL SPRAY $259.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $129.50 $38.85 $25.90 $38.85 $51.80 $51.80 $0.00 407159161 "FERROUS SULFATE 325 MG TABLET, EACH" $6.00 259 4/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407159221 "PRAMIPEXOLE 1 MG TABLET, EACH" $7.00 259 2/2/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407159301 "hydroCHLOROthiazide 25 MG TABLET, EACH" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407159501 "FAMOTIDINE 20 MG TABLET, EACH" $7.00 259 11/26/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407159606 "ASPIRIN-DIPYRIDAMOLE ER 25MG-200 MG CAPSULE, EACH" $7.00 259 11/11/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407159720 "cetirizine HCL 10 MG TABLET, EACH" $6.00 259 9/10/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407159731 EFFEXOR XL 150 $15.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407159746 TERAZOSIN 5MG CAP $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407159902 "naloxone 0.4 MG/ML VIAL 0.4 mg, 1 mL" $10.00 J2310 636 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407160186 SOTROVIMAB INJECTION 500MG/8ML $1.00 Q0247 636 1/26/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407160282 "levETIRAcetam-NaCl 500 MG/100 500 mg, 100 mL" $20.00 J1953 636 11/7/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407160315 "NORTRIPTYLINE HCL 10 MG CAP 1 ea, 50 eaches" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407160382 "levETIRAcetam-NaCl 1,000MG/100 ml PREMIXED BAG, EACH" $20.00 J1953 636 12/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407160415 "NORTRIPTYLINE HCL 25 MG CAPSULE, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407160433 FERROUS GLUCONATE $1.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407160444 TAMOXIFEN TAB 20MG $10.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407160505 SOTALOL 120MG TAB $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407160515 "NORTRIPTYLINE HCL 50 MG CAPSULE, EACH" $7.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407160851 "PROPOFOL 1,000 MG/100 ML VIAL 1000 mg, 100 mL" $45.00 J2704 636 2/5/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $22.50 $6.75 $4.50 $6.75 $9.00 $9.00 $0.00 407161110 "MIDAZOLAM 100MG/100ML-0.9%NACL 100 mg, 100 mL" $25.00 J2250 636 2/8/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407161224 CLINDAMYCIN 600MG/D5W 50 ML PREMIXED BAG $20.00 S0077 636 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407161416 "hydrALAZINE 20 MG/ML VIAL, EACH" $10.00 J0360 636 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407161430 "PHENYTOIN 250 MG/5 ML VIAL 1 ea, 5 mL" $10.00 J1165 636 12/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407161702 ENABLEX ER TAB 7.5MG $30.00 259 1/23/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407162001 PERIDEX 0.12% ORAL RINSE 0-15ML $7.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407162101 MORPHINE 2MG INJ $20.00 J2270 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407162224 "CALCIUM GLU 1,000MG/100ML-NACL 1000 mg, 100 mL" $30.00 250 4/3/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407162301 "BUTORPHANOL 1 MG/ML VIAL, EACH" $10.00 J0595 250 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407162501 "TRUEPLUS GLUCOSE 15 GRAM GEL 1 ea, 32 mL" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407162515 "NITROFURANTOIN MONO-MCR 100 MG 1 ea, 50 eaches" $7.00 259 12/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407162601 "BUTORPHANOL 2 MG/ML VIAL, EACH" $10.00 J0595 636 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407162735 "EAR DROPS 6.5% 1 ea, 15 mL" $6.00 259 2/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407162810 "POLYMYXIN B-TMP EYE DROPS 10 mL, EACH" $10.00 259 7/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407163005 "ATROPINE 0.05 MG/ML SYRINGE 1 ea, 5 mL" $35.00 J0461 636 1/25/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 407163101 "METOCLOPRAMIDE 10 MG TABLET, EACH" $7.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407163110 "NEOMYCIN-POLYMYXIN-HC EAR SOLN 1 ea, 10 mL" $75.00 259 9/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 407163115 "QUEtiapine FUMARATE 50 MG TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407163201 "VECURONIUM 10 MG VIAL, EACH" $10.00 250 2/8/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407163305 "gentamicin 0.3% EYE DROP 1 ea, 5 mL" $10.00 259 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407163562 "NEOMYCIN-POLYMYXIN-HC EAR SUSP 1 ea, 10 mL" $75.00 259 9/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 407163585 FOSAMAX 70MG TAB $76.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $38.00 $11.40 $7.60 $11.40 $15.20 $15.20 $0.00 407163615 "pantoprazole SOD DR 20 MG TABLET, EACH" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407163724 "SODIUM BICARB 8.4% ABBOJECT 50 ML, EACH" $20.00 250 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407164061 "QUEtiapine FUMARATE 100 MG TABLET, EACH" $7.00 259 11/19/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407164070 DEMEROL 75MG/CC INJ $20.00 J2175 636 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407164415 "oxyCODONE-acetaminophen 5-325 tablet, 1 each" $10.00 259 1/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407164501 "CARISOPRODOL 350 MG TABLET, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407164615 "oxyCODONE-acetaminophen 10-325 tablet, 1 each" $10.00 259 1/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407164666 ABILIFY 2MG TAB $75.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 407164860 "RIVASTIGMINE 1.5 MG CAPSULE, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407164901 INFUVITE ADULT MULTIPLE VITAMIN INJECTION 10ML $15.00 A9153 636 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407164912 MILK OF MAGNESIA SUSPENSION 0-30ML $6.00 259 9/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407164960 "RIVASTIGMINE 3 MG CAPSULE, EACH" $7.00 259 2/27/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407165062 "HEPARAIN 25,000 UNITS IN 0.45% NS IV SOLUTION, 1 BAG" $20.00 J1644 636 10/30/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407165116 "levETIRAcetam 100 MG/ML SOLN 100 mg pe, 473 mL" $7.00 259 10/14/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407165128 POTASSIUM GLUCONATE 595MG TAB $2.00 259 1/26/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 407165501 "TRIAMCINOLONE ACET 40MG PER ML, 1ML" $10.00 J3301 636 2/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407165621 "LISINOPRIL 2.5 MG TABLET, EACH" $7.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407165701 "TRIAMCINOLONE ACET 40 MG/ML VL 1 ea, 1 mL" $10.00 J3301 636 4/29/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407165906 "rifAMPin 300 MG CAPSULE, EACH" $7.00 259 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407166203 "CALCITRIOL 0.25 MCG CAPSULE, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407166415 "propranoloL 40 MG TABLET, EACH" $7.00 259 10/27/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407166416 "diphenhydrAMINE 50 MG/ML VIAL 50 mg, 1 mL" $10.00 J1200 636 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407166501 "TERBUTALINE SULF 1 MG/ML 1ML VIAL, EACH" $10.00 J3105 636 5/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407166561 "gabapentin 100 MG CAPSULE, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407166761 "GABAPENTIN 400 MG CAPSULE, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407167104 "DEXTROSE 5%-0.45% NS 1000 mL W/KCL 20MEQ IV SOLUTION 1000 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407167511 "OSELTAMIVIR PHOS 30 MG CAPSULE, EACH" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407167601 "ALPRAZolam 0.25 MG TABLET, EACH" $10.00 259 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407167611 "OSELTAMIVIR PHOS 45 MG CAPSULE, EACH" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407167621 "HYDROCORTISONE AC 25 MG SUPP, 1 EACH" $7.00 259 9/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407167701 "ALPRAZolam 0.5 MG TABLET, EACH" $10.00 259 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407167711 "OSELTAMIVIR PHOS 75 MG CAPSULE, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407167761 "PARoxetine HCL 20 MG TABLET, EACH" $7.00 259 6/18/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407167801 "ALPRAZolam 1 MG TABLET, EACH" $10.00 259 6/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407168382 ETOMIDATE 20MG INJ $25.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407168415 "PROCHLORPERAZINE 5 MG TABLET, EACH" $7.00 259 10/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407168512 NovoLOG Mix 70-30 INSULIN 0-5 UNITS $7.00 J1815 250 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407168615 "nystatin 100,000 UNIT/GM OINT 15GM, EACH" $10.00 259 2/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407168712 LEVEMIR U-100 INSULIN 0-5 UNITS $10.00 J1815 636 10/24/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407169041 "ACETYLCYSTEINE 20% VIAL 200 mg pe, 30 mL" $10.00 J7608 636 10/14/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407169104 "SODIUM CHLORIDE 0.9% WITH KCL 20 MEQ IV SOLUTION 1000ML, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407169404 "ACETYLCYSTEINE 20% VIAL 1 ea, 4 mL" $7.00 J7608 636 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407169480 "CHLORASEPTIC SORE THROAT SPRAY 1 ea, 20 mL" $6.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407169501 "BUTALB-ACETAMIN-CAFF 50-325-40 1 ea, 100 eaches" $7.00 259 10/14/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407169504 "ACETYLCYSTEINE 10% VIAL 100 mg pe, 4 mL" $7.00 J7608 636 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407169761 LEVEMIR INSULIN PER 5UNITS $6.00 J1815 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407169921 "CEFDINIR 300 MG CAPSULE, EACH" $7.00 259 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407169924 "PROPOFOL 1,000 MG/100 ML VIAL 1000 mg, 100 mL" $35.00 J2704 636 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 407169960 "cefUROXime axetiL 250 MG TABLET, EACH" $7.00 259 11/26/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407170001 "INS. NOVOLIN 70/30, PER 5 UNITS" $6.00 J1815 259 2/1/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407170009 THEOPHYLLINE ER TAB 200MG $1.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407170022 TOBRADEX OPTH SOL $133.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $66.50 $19.95 $13.30 $19.95 $26.60 $26.60 $0.00 407170025 "SUCCINYLCHOLINE 200 MG/10 ML 200 mg, 10 mL" $20.00 J0330 636 2/8/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407170028 "MAGNESIUM OXIDE 400 MG TABLET, EACH" $6.00 259 12/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407170038 "OYSTER SHELL 500MG-VIT D3 5MCG TABLET, EACH" $6.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407170195 "cefTRIAXone 1 GM VIAL, EACH" $10.00 J0696 636 12/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407170225 "DROPERIDOL 5 MG/2 ML VIAL, EACH" $15.00 J1790 636 11/17/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407170461 "PRAMIPEXOLE 0.25 MG TABLET 0.25 mg, 100 eaches" $7.00 259 2/8/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407170510 IMIPENEM-CILASTATIN 500 MG VIAL $20.00 J0743 636 2/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407170561 "PROPRANOLOL 20 MG TABLET, EACH" $7.00 259 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407170601 "CHLORDIAZEPOXIDE 5MG-CLIDINIUM 2.5MG CAPSULE, 1 EACH" $7.00 259 11/4/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407170606 "OMEGA-3 ETHYL ESTERS 1 GM CAPSULE, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407170685 JANUVIA 100MG TAB $28.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 407170915 "rosuvastatin CALCIUM 10 MG TABLET, EACH" $7.00 259 3/5/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407170996 "PHYTONADIONE 1 MG/0.5 ML VIAL 1 ea, 0.5 mL" $10.00 J3430 636 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407171015 "rosuvastatin CALCIUM 20 MG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407171020 "methadone HCL 10 MG TABLET, EACH" $7.00 259 11/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407171401 "BENZONATATE 100 MG CAPSULE, EACH" $7.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407171513 "mannitoL 20% IV SOLUTION 100 g, 500 mL" $30.00 250 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407172224 "levoFLOXacin 250 MG/50 ML-D5W 1 ea, 50 mL" $10.00 J1956 636 8/21/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407172259 RISPERDAL .5MG TAB $8.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 407172415 "sotaloL 80 MG TABLET, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407172514 MINTOX MAXIMUM STRENGTH SUSPENSION 0-30ML $6.00 259 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407172515 "sotaloL 120 MG TABLET, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407172525 "ketorolac 60 MG/2 ML VIAL, EACH" $10.00 J1885 636 5/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407172561 "SULFAMETHOXAZOLE-TMP DS TABLET, EACH" $7.00 259 10/29/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407172757 SULFAMETHOXAZOLE-TMP SUSPENSION 0-20ML $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407172810 "MICAFUNGIN 50 MG VIAL 50 mg, 1 each" $30.00 J2248 636 9/11/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407172815 "SULFAMETHOXAZOLE-TMP SS TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407173032 "ACETAMINOPHEN 650 MG SUPPOSITORY, EACH" $6.00 259 10/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407173061 "ACETAMINOPHEN 500 MG TABLET, EACH" $6.00 259 1/25/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407173102 "terbinafine HCL 250 MG TABLET, EACH" $7.00 259 1/23/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407173204 "colchicine 0.6 MG CAPSULE, EACH" $7.00 259 11/5/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407173230 "ACETAMINOPHEN 120 MG SUPPOSITORY, EACH" $6.00 259 10/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407173320 "HALOPERIDOL 0.5 MG TABLET 0.5 mg, 100 eaches" $7.00 259 1/15/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407173401 "DULoxetine HCL DR 30 MG CAPSULE, EACH" $7.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407173925 "predniSONE 1 MG TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407174115 "rOPINIRole HCL 0.25 MG TABLET 1 ea, 50 eaches" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407174957 "FOSFOMYCIN 3 GM SACHET 3 g, 1 each" $30.00 259 8/5/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407175025 "TRIAMTERENE-HCTZ 37.5-25 MG TB 1 ea, 30 eaches" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407175102 "FAMOTIDINE 20 MG/2 ML VIAL 1 ea, 2 mL" $10.00 250 8/21/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407175201 "VITAMIN E 180 MG (400IU) SOFTGEL, EACH" $6.00 259 11/17/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407175221 "TUBERSOL (PPD) 5TU/0.1ML SKIN TEST, EACH" $20.00 250 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407175320 "SUCRALFATE 1 GM TABLET, EACH" $7.00 259 10/24/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407175321 "AZITHROMYCIN 500 MG TABLET, EACH" $7.00 259 10/6/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407175415 "MAGNESIUM SULFATE 50% SYRINGE 5 g, 10 mL" $28.00 250 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 407175618 CASIRIVMAB/IMDEVIMAB 600MG POST ADMIN MONITORING OUTPATIENT $675.00 Q0240 636 1/1/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $337.50 $101.25 $67.50 $101.25 $135.00 $135.00 $0.00 407175699 EXELON PATCH 9.5MG $28.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 407175908 prednisoLONE 15 MG/5 ML ORAL SOLUTION 0-5ML $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407175920 "ATENOLOL 25 MG TABLET, EACH" $7.00 259 11/4/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407176015 "tiZANidine HCL 4 MG TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407176058 "cycloSPORINE 0.05% EYE EMULS 0.4 mL, EACH" $10.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407176410 "WARFARIN SODIUM 3 MG TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407176415 "TERAZOSIN 1 MG CAPSULE, EACH" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407176520 CHILDREN'S CETIRIZINE 1MG/ML ORAL SOLUTION 0-10ML $6.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407176620 CHLD ACETAMINOPHEN 160MG/5 ML ORAL SUSP 0-15ML $6.00 259 11/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407177615 "traZODone 150 MG TABLET, EACH" $7.00 259 3/5/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407177805 "metoprolol tart 5 MG/5 ML VIAL 1 ea, 5 mL" $10.00 250 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407178201 "METHENAMINE HIPP 1 GM TABLET, EACH" $7.00 259 9/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407178261 "DIVALPROEX SOD DR 500 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407178401 "ASTHMANEFRIN RFILL 2.25% INH SOLU 0.5ML, EACH" $10.00 J7699 636 2/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407178461 "FLUoxetine HCL 10 MG CAPSULE, EACH" $7.00 259 12/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407178561 "FLUoxetine HCL 20 MG CAPSULE, EACH" $7.00 259 1/1/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407179216 "VALPROIC ACID 250 MG/5 ML ORAL SOLUTION, 0-5ML" $7.00 259 11/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407179225 ALBUKED-25 (HUMAN ALBUMIN 25%) VIAL 12.5GM PER 50ML $90.00 P9047 636 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $45.00 $13.50 $9.00 $13.50 $18.00 $18.00 $0.00 407179489 "ASPIRIN 81 MG CHEWABLE TABLET, EACH" $6.00 259 10/12/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407179596 KEPPRA TAB 500MG $10.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407179761 "LISINOPRIL 5 MG TABLET, EACH" $7.00 259 11/21/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407179801 "POTASSIUM CL ER 600MG (8MEQ) CAPSULE, EACH" $7.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407179848 NITROGLYCERIN PATCH 0.2 $5.00 259 1/10/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407179861 "LISINOPRIL 10 MG TABLET, EACH" $7.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407179869 NITROGLYCERING 0.6 PATCH $5.00 259 3/24/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407179888 "POLYSPORIN OINTMENT 15 GRAMS, EACH" $10.00 259 11/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407179961 "LISINOPRIL 20 MG TABLET, EACH" $7.00 259 10/24/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407180025 "LEVALBUTEROL 0.63 MG/3 ML INH SOL, EACH" $7.00 J7614 636 2/2/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407180304 "D5NS WITH KCL 20MEQ IV SOLUTION 1000 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407180567 "TRIPLE ANTIBIOTIC OINTMENT 0.9GM PACKET, EACH" $6.00 259 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407180602 "fentaNYL 100 MCG/2 ML VIAL 1 ea, 2 mL" $10.00 J3010 636 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407180806 "MONTELUKAST SOD 10MG TABLET, EACH" $7.00 259 11/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407181555 "BUDESONIDE 0.25 MG/2 ML INH SUSP, EACH" $10.00 J7626 636 11/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407181615 "acetic acid 2% EAR SOLUTION 1 ea, 15 mL" $25.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407181655 "BUDESONIDE 0.5 MG/2 ML SUSP 1 ea, 2 mL" $10.00 J7626 636 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407181673 "BUDESONIDE 0.5 MG/2 ML SUSP 1 ea, 2 mL" $10.00 J7626 636 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407182152 "Engerix-B 20 MCG/ML PREFILLED SYRINGE, EACH" $91.00 90746 636 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $45.50 $13.65 $9.10 $13.65 $18.20 $18.20 $0.00 407182306 "CALCITONIN-SALMON NASAL SPRAY 3.7ML BOTTLE, EACH" $25.00 259 5/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407182361 "GABAPENTIN 600 MG TABLET, EACH" $7.00 259 7/15/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407182461 "HYDROcodone-acetamin 5-325 MG tablet, 1 each" $10.00 259 1/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407182501 "Solu-CORTEF 100 MG VIAL 1 ea, 1 each" $25.00 J1720 636 3/5/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407182561 "HYDROcodone-acetamin 10-325 MG tablet, 1 each" $10.00 259 1/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407182776 VIT D TAB $1.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407182800 "CHILD IBUPROFEN 200MG/10ML CUP 1 ea, 10 mL" $6.00 259 2/1/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407182901 FLUTICASONE PROPPIONATE 50MCG NASAL SPRAY 16GM BOTTLE $10.00 259 2/23/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407182936 NIASPAN 500MG TAB $6.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407183011 "dilTIAZem 24H ER(CD) 180 MG CAPSULE, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407183082 "ZOLEDRONIC ACID 5 MG/100 ML PREMIXED BAG, EACH" $65.00 J3489 636 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $32.50 $9.75 $6.50 $9.75 $13.00 $13.00 $0.00 407183311 NOVOLIN R U-100 INSULIN 0-5 UNITS $10.00 259 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407183411 NovoLIN N U-100 INSULIN 0-5 UNITS $10.00 J1815 636 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407183625 "DOXAZOSIN MESYLATE 1 MG TABLET, EACH" $7.00 259 4/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407183711 NovoLIN 70-30 100 UNIT/ML INSULIN 0-5 UNITS $10.00 J1815 636 10/24/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407184064 "IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 1 ea, 3 mL" $7.00 J7620 636 8/21/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407184087 "IPRAT-ALBUT 0.5-3(2.5) MG/3 ML 1 ea, 3 mL" $7.00 J7620 636 8/21/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407184501 "OXcarbazepine 150 MG TABLET, EACH" $7.00 259 12/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407184777 PRISTIQ 100MG TAB $20.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407184858 "ZIPRASIDONE 20 MG/ML VIAL, EACH" $25.00 J3486 636 7/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 407185000 "GLUCAGON 1 MG EMERGENCY KIT, EACH" $280.00 J1610 636 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $140.00 $42.00 $28.00 $42.00 $56.00 $56.00 $0.00 407185361 "IBUPROFEN 400 MG TABLET, EACH" $7.00 259 11/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407185404 "ADENOSINE 12 MG/4 ML VIAL 1 ea, 4 mL" $10.00 J0153 636 4/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407185461 "IBUPROFEN 600 MG TABLET, EACH" $7.00 259 11/11/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407185561 "IBUPROFEN 800 MG TABLET, EACH" $7.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407185901 "FAMOTIDINE 20 MG TABLET, EACH" $7.00 259 11/26/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407185915 "VITAMIN B-6 100 MG TABLET, EACH" $6.00 259 3/5/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407185931 ACCUPRIL 10MG TAB $3.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407186315 "VITAMIN D3 400 UNIT TABLET, EACH" $6.00 259 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407186445 SELEGILINE TAB 5MG $8.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 407186515 "VITAMIN D3 2,000 UNIT TABLET, EACH" $6.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407186815 "VITAMIN D3 5,000 UNIT SOFTGEL, EACH" $6.00 259 12/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407186861 "traZODone 50 MG TABLET, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407186961 "traZODone 100 MG TABLET, EACH" $7.00 259 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407187044 "MEMANTINE HCL 5 MG TABLET, EACH" $7.00 259 5/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407187045 "pantoprazole SOD DR 40 MG TABLET, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407187199 "cloNIDine 0.1 MG/DAY PATCH 1 ea, 4 eaches" $15.00 259 10/17/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 407187299 cloNIDine 0.2 MG/DAY PATCH $22.00 259 2/27/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $11.00 $3.30 $2.20 $3.30 $4.40 $4.40 $0.00 407187525 "amiodarone 150 MG/3 ML VIAL 1 ea, 3 mL" $10.00 J0282 636 7/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407187544 "MEMANTINE HCL 10 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407188014 "NYSTATIN-TRIAMCINOLONE CREAM 1 ea, 15 g" $20.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407188361 "OYSTER SHELL CALCIUM 500 MG TABLET, EACH" $6.00 259 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407188720 "WATER FOR INJECTION VIAL 1 ea, 20 mL" $10.00 250 12/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407189261 "PRAVASTATIN SODIUM 20 MG TABLET, EACH" $7.00 259 7/15/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407189301 "morphine 10 MG/ML CARPUJECT 1 ea, 1 mL" $10.00 J2270 636 8/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407189331 "ELIQUIS 2.5 MG TABLET, EACH" $11.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 407189361 "pravastatin SODIUM 40 MG TABLET, EACH" $7.00 259 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407189431 "ELIQUIS 5 MG TABLET, EACH" $11.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.50 $1.65 $1.10 $1.65 $2.20 $2.20 $0.00 407189603 "ARIPiprazole 2 MG TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407190004 "CHLORTHALIDONE 25 MG TABLET, EACH" $7.00 259 4/10/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407190025 "LEVALBUTEROL 1.25 MG/3 ML SOL 1 ea, 3 mL" $7.00 J7614 636 2/2/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407190091 "CALCIUM CHLORIDE 1 GM/10ML SYR 1 ea, 10 mL" $10.00 250 1/15/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407190102 "VEKLURY 100 MG VIAL 100 mg, EACH" $900.00 J0248 636 6/4/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $450.00 $135.00 $90.00 $135.00 $180.00 $180.00 $0.00 407190186 "SOTROVIMAB 500 MG/8 ML VL(EUA) 500 mcg, 8 mL" $1.00 Q0247 636 1/27/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 407190199 "S2 RACEPINEPHRINE 2.25% INH SOL 0.5ML, EACH" $10.00 J7699 636 2/9/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407190264 "DEXTROSE 50%-WATER ABBOJECT 50 mL, 1 SYRINGE" $20.00 250 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407190334 "LIDOCAINE HCL 2% ABBOJECT 100 mg, 5 mL" $20.00 J2001 636 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407190401 "LORazepam 0.5 MG TABLET, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407190434 "LIDOCAINE HCL 1% ABBOJECT 1 ea, 5 mL" $20.00 J2001 636 11/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407190471 "ADMIN TET/DIPH,PERTUSSIS INJ" $60.00 90471 771 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $30.00 $9.00 $6.00 $9.00 $12.00 $12.00 $0.00 407190671 PREVNAR ADMINISTRATION $30.00 G0009 771 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407191001 "DIPHENOXYLATE-ATROPINE 2.5-0.025MG TABLET, EACH" $10.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407191011 "ATROPINE 0.5 MG/5 ML ABBOJECT, EACH" $20.00 J0461 636 10/31/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407191013 HYDROCORTISONE TAB 20MG $5.00 259 1/23/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $2.50 $0.75 $0.50 $0.75 $1.00 $1.00 $0.00 407191459 "IBUPROFEN 200 MG TABLET, EACH" $6.00 259 11/11/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407191461 "IBUPROFEN 200 MG TABLET, EACH" $6.00 259 11/15/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407191501 "Lovenox 150 MG/ML SYRINGE, EACH" $20.00 J1650 636 11/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407191789 MORPHINE IR 15MG TAB $3.00 259 5/1/2017 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 407191939 "cetirizine HCL 10 MG TABLET, EACH" $6.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407192101 "ASPIRIN EC 325 MG TABLET, EACH" $6.00 259 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407192161 "DIGOXIN 125 MCG TABLET, EACH" $7.00 259 12/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407192320 "CARBIDOPA-LEVO ER 50-200 TABLET, EACH" $7.00 259 8/17/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407192361 "predniSONE 10 MG TABLET, EACH" $7.00 259 4/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407192561 "sertraline HCL 50 MG TABLET, EACH" $7.00 259 10/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407192661 "sertraline HCL 100 MG TABLET, EACH" $7.00 259 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407192716 "PROMETHAZINE 6.25 MG/5 ML SOLN, 0-10ML" $7.00 259 5/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407192761 "SPIRONOLACTONE 25 MG TABLET, EACH" $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407193061 "POTASSIUM CL ER 10 MEQ CAPSULE, EACH" $7.00 259 12/31/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407194004 "NOREPINEPHRINE 4 MG/4 ML VIAL, EACH" $20.00 250 5/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 407194961 "levothyroxine 25 MCG TABLET, EACH" $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407195061 "LEVOTHYROXINE 50 MCG TABLET, EACH" $7.00 259 10/13/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407195161 "levothyroxine 75 MCG TABLET, EACH" $7.00 259 10/2/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407195261 "levothyroxine 88 MCG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407195361 "levothyroxine 100 MCG TABLET, eachs" $7.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407195461 "levothyroxine 112 MCG TABLET, EACH" $7.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407195761 "levothyroxine 175 MCG TABLET 175 mcg, 100 eaches" $7.00 250 8/19/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407195961 "CLINDAMYCIN HCL 150MG CAPSULE, EACH" $7.00 259 12/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407196444 LUMIGAN OPTH SOL. $190.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $95.00 $28.50 $19.00 $28.50 $38.00 $38.00 $0.00 407196510 "POTASSIUM CHLORIDE 20MEQ/10ML CONC INJECTION, EACH" $10.00 J3480 636 4/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407198310 "ZINC SULFATE 220 MG CAPSULE, EACH" $6.00 259 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 407198321 "PIPERACIL-TAZOBACTAM 3.375 GM VIAL, EACH" $30.00 J2543 636 11/2/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $15.00 $4.50 $3.00 $4.50 $6.00 $6.00 $0.00 407198761 "DICYCLOMINE 10 MG CAPSULE, EACH" $7.00 259 12/7/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407198861 "DICYCLOMINE 20 MG TABLET 20 mg, 100 eaches" $7.00 259 12/4/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 407199261 "PREGABALIN 50 MG CAPSULE, EACH" $10.00 259 11/8/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 407199361 "amiodarone HCL 200 MG TABLET, EACH" $7.00 259 10/8/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071000102 "ETHYL CHLORIDE SPRAY 1 ea, 116 mL" $45.60 259 12/21/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $22.80 $6.84 $4.56 $6.84 $9.12 $9.12 $0.00 4071001101 "ARTIFICIAL TEARS DROPS 1 ea, 15 mL" $6.00 259 11/11/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 4071004902 "SODIUM CHLORIDE 0.9% IV SOLUTION 250 mL, 1 BAG" $20.00 258 10/28/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 4071005801 "glyBURIDE 5 MG TABLET, EACH" $7.00 259 9/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071014601 "TEMAZEPAM 15 MG CAPSULE, EACH" $10.00 259 9/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 4071027603 "DONEPEZIL HCL 10 MG TABLET, EACH" $7.00 259 9/14/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071033801 "CARBIDOPA-LEVODOPA 10-100 TABLET, EACH" $7.00 259 9/26/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071040966 "POTASSIUM CL 10 MEQ/5 ML CONC 10 mEq, 5 mL" $20.00 J3480 636 11/18/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 4071046530 "NYAMYC 100,000 UNIT/GM POWDER 1 ea, 30 g" $15.00 259 11/3/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $7.50 $2.25 $1.50 $2.25 $3.00 $3.00 $0.00 4071067801 OSELTAMIVIR 6 MG/ML SUSPENSION 0-12.5ML $10.00 259 2/5/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 4071070025 "LEVALBUTEROL 0.31 MG/3 ML SOL 1 ea, 3 mL" $10.00 J7614 636 7/15/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 4071100200 "ZINC 50 MG TABLET, EACH" $6.00 259 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 4071113130 "DUTASTERIDE 0.5 MG CAPSULE, EACH" $7.00 259 5/22/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071114880 TYLENOL # 3 TAB $3.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.50 $0.45 $0.30 $0.45 $0.60 $0.60 $0.00 4071115353 LEVOPHED 4MG/4ML INJ $55.00 250 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $27.50 $8.25 $5.50 $8.25 $11.00 $11.00 $0.00 4071115600 "COENZYME Q-10 200 MG SOFTGEL, EACH" $6.00 259 2/27/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 4071120001 GUAIFENESIN DM PER 5ML $2.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $1.00 $0.30 $0.20 $0.30 $0.40 $0.40 $0.00 4071263301 "CITALOPRAM HBR 40 MG TABLET, EACH" $7.00 259 5/11/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071316201 "ketorolac 30 MG/ML VIAL 1 ea, 1 mL" $10.00 J1885 636 11/30/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 4071331801 "EPINEPHrine 1 MG/10 ML LUERJET 1 ea, 10 mL" $20.00 J0171 636 11/16/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 4071464501 "tiZANidine HCL 4 MG TABLET, EACH" $7.00 259 10/14/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071550261 "ENALAPRIL MALEATE 5 MG TABLET, EACH" $7.00 259 1/1/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071576646 CHLORTHALIDONE 25MG TABLET $8.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $4.00 $1.20 $0.80 $1.20 $1.60 $1.60 $0.00 4071622019 "SENNOSIDES-DOCUSATE SODIUM TABLET, EACH" $6.00 259 9/10/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 4071698520 diphenhydrAMINE 12.5 MG/5 ML ORAL LIQUID 0-10ML $6.00 259 9/28/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.00 $0.90 $0.60 $0.90 $1.20 $1.20 $0.00 4071700861 "lamoTRIgine 100 MG TABLET, EACH" $7.00 259 2/2/2024 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071705261 "DOXEPIN 10 MG CAPSULE, EACH" $7.00 259 2/18/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071705361 "DOXEPIN 25 MG CAPSULE, EACH" $7.00 259 11/27/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $3.50 $1.05 $0.70 $1.05 $1.40 $1.40 $0.00 4071968910 "niCARdipine 25 MG/10 ML VIAL, EACH" $25.00 250 5/13/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 4407100115 BUTRANS PATCH 10MG $137.00 259 7/1/2018 zzLRMH_CC_Pharmacy $0.00 $0.00 $68.50 $20.55 $13.70 $20.55 $27.40 $27.40 $0.00 40713026910 "Diprivan 100 MG/10 ML VIAL 100 mg, 10 mL" $10.00 J2704 636 11/7/2021 zzLRMH_CC_Pharmacy $0.00 $0.00 $5.00 $1.50 $1.00 $1.50 $2.00 $2.00 $0.00 4071 04648 "FLUCONAZOLE 200MG IN 0.9% SODIUM CHLORIDE 100ML PREMIXED BAG, 1 EACHg, 100 mL" $20.00 J1450 636 7/15/2023 zzLRMH_CC_Pharmacy $0.00 $0.00 $10.00 $3.00 $2.00 $3.00 $4.00 $4.00 $0.00 COVIDSOTROVOP SOTROVIMAB ANTIBODY SQ/IV WITH POST ADMIN MONITORING OUTPATIENT $675.00 Q0247 636 1/26/2022 zzLRMH_CC_Pharmacy $0.00 $0.00 $337.50 $101.25 $67.50 $101.25 $135.00 $135.00 $0.00 40291111 CODA PT MEDICAID $50.00 97110 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $25.00 $7.50 $5.00 $7.50 $10.00 $10.00 $0.00 40298981 MOBILITY CURRENT STATUS $1.00 G8981 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40298982 MOBILITY GOAL STATUS $1.00 G8982 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918978 MOBILITY CURRENT STATUS $1.00 G8978 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918979 MOBILITY GOAL STATUS $1.00 G8979 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918980 MOBILITY D/C STATUS $1.00 G8980 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918981 BODY POSITION CURRENT STATUS $1.00 G8981 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918982 BODY POSITION GOAL STATUS $1.00 G8982 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918983 BODY POSITION D/C STATUS $1.00 G8983 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918984 CARRY CURRENT STATUS $1.00 G8984 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918985 CARRY GOAL STATUS $1.00 G8985 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918986 CARRY D/C STATUS $1.00 G8986 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918987 SELF CARE CURRENT STATUS $1.00 G8987 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918988 SELF CARE GOAL STATUS $1.00 G8988 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918990 OTHER PT/OT CURRENT STATUS $1.00 G8990 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918991 OTHER PT/OT GOAL STATUS $1.00 G8991 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40918992 OTHER PT/OT D/C STATUS $1.00 G8992 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 402997034 CONTRAST BATH PER 15 MIN $35.00 97034 421 1/1/2021 zzLRMH_CC_PT $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 409197002 PT RE-EVALUATION $113.00 97002 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 409197010 HOT/COLD MOIST PACK $25.00 97010 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $12.50 $3.75 $2.50 $3.75 $5.00 $5.00 $0.00 409197012 MECHANICAL TRACTION PER 15 MINS $63.00 97012 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 409197014 ELECTRICAL STIMULATION UNATTENDED $43.00 97014 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $21.50 $6.45 $4.30 $6.45 $8.60 $8.60 $0.00 409197022 WHIRLPOOL EXTREMITY $36.00 97022 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 409197026 INFRARED $28.00 97026 420 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $14.00 $4.20 $2.80 $4.20 $5.60 $5.60 $0.00 409197032 ELECTRICAL STIMULATION PER 15 $46.00 97032 421 7/2/2020 zzLRMH_CC_PT $0.00 $0.00 $23.00 $6.90 $4.60 $6.90 $9.20 $9.20 $0.00 409197033 IONTOPHORESIS PER 15 MIN $48.00 97033 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $24.00 $7.20 $4.80 $7.20 $9.60 $9.60 $0.00 409197034 CONTRAST BATH PER 15 MIN $35.00 97034 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $17.50 $5.25 $3.50 $5.25 $7.00 $7.00 $0.00 409197035 ULTRASOUND PER 15 MIN $36.00 97035 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $18.00 $5.40 $3.60 $5.40 $7.20 $7.20 $0.00 409197110 THERAPUTIC EXERCISES PER 15 MN $71.00 97110 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $35.50 $10.65 $7.10 $10.65 $14.20 $14.20 $0.00 409197112 NEURO RE-EDUCATION $71.00 97112 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $35.50 $10.65 $7.10 $10.65 $14.20 $14.20 $0.00 409197116 GAIT TRAINING PER 15 MINS. $61.00 97116 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $30.50 $9.15 $6.10 $9.15 $12.20 $12.20 $0.00 409197124 MASSAGE $57.00 97124 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $28.50 $8.55 $5.70 $8.55 $11.40 $11.40 $0.00 409197140 MYOFACIAL RELEASE/MANUAL TRACTION $63.00 97140 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $31.50 $9.45 $6.30 $9.45 $12.60 $12.60 $0.00 409197161 PT EVAL LOW COMPLEXITY $218.00 97161 424 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $109.00 $32.70 $21.80 $32.70 $43.60 $43.60 $0.00 409197162 PT EVAL MODERATE COMPLEXITY $218.00 97162 424 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $109.00 $32.70 $21.80 $32.70 $43.60 $43.60 $0.00 409197163 PT EVAL HIGH COMPLEXITY $218.00 97163 424 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $109.00 $32.70 $21.80 $32.70 $43.60 $43.60 $0.00 409197164 PT RE-EVALUATION $113.00 97164 424 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 409197530 THERAPUTIC ACTIVTIES PER 15 MN $74.00 97530 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $37.00 $11.10 $7.40 $11.10 $14.80 $14.80 $0.00 409197535 HEP/ADL $75.00 97535 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $37.50 $11.25 $7.50 $11.25 $15.00 $15.00 $0.00 409197750 PHYS PREFORM W/REPORT PER 15MN $79.00 97750 421 7/1/2018 zzLRMH_CC_PT $0.00 $0.00 $39.50 $11.85 $7.90 $11.85 $15.80 $15.80 $0.00 404110 ABDOMEN ACUTE SERIES $265.00 74022 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $132.50 $39.75 $26.50 $39.75 $53.00 $53.00 $0.00 404112 ABDOMEN 2 VIEWS $229.00 74019 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $114.50 $34.35 $22.90 $34.35 $45.80 $45.80 $0.00 404120 ABDOMEN 1 VIEW $161.00 74018 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $80.50 $24.15 $16.10 $24.15 $32.20 $32.20 $0.00 404130 ANKLE $129.00 73600 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $64.50 $19.35 $12.90 $19.35 $25.80 $25.80 $0.00 404140 CHEST 1-VIEW $147.00 71045 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 404150 CHEST 2 VIEWS $190.00 71046 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $95.00 $28.50 $19.00 $28.50 $38.00 $38.00 $0.00 404190 ELBOW $131.00 73070 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $65.50 $19.65 $13.10 $19.65 $26.20 $26.20 $0.00 4041110 FACIAL BONES $166.00 70150 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $83.00 $24.90 $16.60 $24.90 $33.20 $33.20 $0.00 4041120 FEMUR 2-VIEWS $158.00 73552 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $79.00 $23.70 $15.80 $23.70 $31.60 $31.60 $0.00 4041130 FINGER MIN 2 VIEW $116.00 73140 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $58.00 $17.40 $11.60 $17.40 $23.20 $23.20 $0.00 4041150 FOOT $161.00 73620 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $80.50 $24.15 $16.10 $24.15 $32.20 $32.20 $0.00 4041160 FOREARM $152.00 73090 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 4041180 HAND $147.00 73120 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 4041190 HIP JOINT 2 VIEWS $202.00 73502 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $101.00 $30.30 $20.20 $30.30 $40.40 $40.40 $0.00 4041191 HIP 2 VIEW BILATERAL $401.00 73521 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $200.50 $60.15 $40.10 $60.15 $80.20 $80.20 $0.00 4041200 JAW MANDIBLE $152.00 70100 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $76.00 $22.80 $15.20 $22.80 $30.40 $30.40 $0.00 4041220 KNEE - 1 OR 2 VIEWS $147.00 73560 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 4041221 KNEE 3 VIEWS $160.00 73562 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $80.00 $24.00 $16.00 $24.00 $32.00 $32.00 $0.00 4041230 LEG TIBIA & FIBULA $147.00 73590 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 4041250 PELVIS $146.00 72170 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 4041260 PYELOGRAM IV $450.00 74400 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $225.00 $67.50 $45.00 $67.50 $90.00 $90.00 $0.00 4041270 RIBS ONE SIDE 2-VIEWS $265.00 71100 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $132.50 $39.75 $26.50 $39.75 $53.00 $53.00 $0.00 4041280 SHOULDER MINIMUM 2 VIEWS $158.00 73030 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $79.00 $23.70 $15.80 $23.70 $31.60 $31.60 $0.00 4041290 SINUSES $163.00 70220 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $81.50 $24.45 $16.30 $24.45 $32.60 $32.60 $0.00 4041300 SKULL - SERIES COMPLETE $236.00 70260 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $118.00 $35.40 $23.60 $35.40 $47.20 $47.20 $0.00 4041303 ANKLE 3 VIEWS $193.00 73610 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $96.50 $28.95 $19.30 $28.95 $38.60 $38.60 $0.00 4041320 "SPINE, CERVICAL" $265.00 72040 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $132.50 $39.75 $26.50 $39.75 $53.00 $53.00 $0.00 4041321 C-SPNE W/ OBLIQUE $365.00 72050 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $182.50 $54.75 $36.50 $54.75 $73.00 $73.00 $0.00 4041330 "DORSAL SPINE, THORACIC 2-VIEWS" $163.00 72070 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $81.50 $24.45 $16.30 $24.45 $32.60 $32.60 $0.00 4041340 "SPINE, LUMBAR" $203.00 72100 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $101.50 $30.45 $20.30 $30.45 $40.60 $40.60 $0.00 4041370 WRIST $161.00 73100 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $80.50 $24.15 $16.10 $24.15 $32.20 $32.20 $0.00 4041380 HUMERUS $146.00 73060 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 4041390 SACRUM AND COCCYX SPINE $147.00 72220 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 4041650 NECK - SOFT TISSUE - 2 VIEWS $163.00 70360 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $81.50 $24.45 $16.30 $24.45 $32.60 $32.60 $0.00 4041900 NOSE $132.00 70160 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $66.00 $19.80 $13.20 $19.80 $26.40 $26.40 $0.00 4041904 "ELBOW, COMPLETE, 3 VIEW" $161.00 73080 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $80.50 $24.15 $16.10 $24.15 $32.20 $32.20 $0.00 4047220 SI JOINTS 1-2 VIEWS $175.00 72200 320 1/1/2021 zzLRMH_CC_Radiology $0.00 $0.00 $87.50 $26.25 $17.50 $26.25 $35.00 $35.00 $0.00 40411010 OS CALCIS (HEEL) $131.00 73650 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $65.50 $19.65 $13.10 $19.65 $26.20 $26.20 $0.00 40411020 HIP JOINT - 1 VIEW $81.00 73501 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $40.50 $12.15 $8.10 $12.15 $16.20 $16.20 $0.00 40411030 KNEE 4 VIEWS (BOTH OBLIQUES) $173.00 73564 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $86.50 $25.95 $17.30 $25.95 $34.60 $34.60 $0.00 40411050 SHOULDER - 1 VIEW $64.00 73020 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 40411060 SKULL - 2 VIEWS $158.00 70250 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $79.00 $23.70 $15.80 $23.70 $31.60 $31.60 $0.00 40411080 "SPINE, LUMBAR - OBLIQUES" $338.00 72110 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $169.00 $50.70 $33.80 $50.70 $67.60 $67.60 $0.00 40411090 ORBITS $174.00 70200 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $87.00 $26.10 $17.40 $26.10 $34.80 $34.80 $0.00 40411501 TOE MIN 2 VIEW $116.00 73660 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $58.00 $17.40 $11.60 $17.40 $23.20 $23.20 $0.00 40411503 FOOT 3 VIEWS $224.00 73630 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $112.00 $33.60 $22.40 $33.60 $44.80 $44.80 $0.00 40411803 HAND 3 VIEWS $208.00 73130 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $104.00 $31.20 $20.80 $31.20 $41.60 $41.60 $0.00 40412010 T-M JOINTS $192.00 70330 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $96.00 $28.80 $19.20 $28.80 $38.40 $38.40 $0.00 40412020 SCAPULA $146.00 73010 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 40412030 STERNUM $146.00 71120 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 40412050 CLAVICLE $147.00 73000 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $73.50 $22.05 $14.70 $22.05 $29.40 $29.40 $0.00 40412060 SKELETAL SURVEY $440.00 77072 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $220.00 $66.00 $44.00 $66.00 $88.00 $88.00 $0.00 40413703 WRIST 3-VIEW $243.00 73110 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $121.50 $36.45 $24.30 $36.45 $48.60 $48.60 $0.00 40472202 SI JOINTS 3+ VIEWS $200.00 72202 320 1/1/2021 zzLRMH_CC_Radiology $0.00 $0.00 $100.00 $30.00 $20.00 $30.00 $40.00 $40.00 $0.00 404171110 RIBS BILATERAL 3 VIEW $529.00 71110 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $264.50 $79.35 $52.90 $79.35 $105.80 $105.80 $0.00 404172010 SPINE COMPLETE $321.00 72082 320 7/1/2018 zzLRMH_CC_Radiology $0.00 $0.00 $160.50 $48.15 $32.10 $48.15 $64.20 $64.20 $0.00 404172081 "RADIOLOGIC EXAM, SPINE ENTIRE T/S 1 VIEW" $53.00 72081 320 9/1/2019 zzLRMH_CC_Radiology $0.00 $0.00 $26.50 $7.95 $5.30 $7.95 $10.60 $10.60 $0.00 404172082 "RADIOLOGIC EXAM, SCOLIOSIS EVAL 2 TO 3 VIEWS" $132.00 72082 320 4/1/2021 zzLRMH_CC_Radiology $0.00 $0.00 $66.00 $19.80 $13.20 $19.80 $26.40 $26.40 $0.00 429510 HOLTER MONITOR $369.00 93225 731 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $184.50 $55.35 $36.90 $55.35 $73.80 $73.80 $0.00 317136600 ARTERIAL PUNCTURE $146.00 36600 410 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 317182805 ABG ANALYSIS $245.00 82805 301 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $122.50 $36.75 $24.50 $36.75 $49.00 $49.00 $0.00 317194002 VENT SETUP INITIAL $501.00 94002 410 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $250.50 $75.15 $50.10 $75.15 $100.20 $100.20 $0.00 317194003 VENT EA SUBSEQUENT DAY $344.00 94003 410 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $172.00 $51.60 $34.40 $51.60 $68.80 $68.80 $0.00 317194150 VT. INTIAL MGT $146.00 94150 460 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $73.00 $21.90 $14.60 $21.90 $29.20 $29.20 $0.00 317194660 BIPAP CPAP INITIAL MANAGEMENT $400.00 94660 410 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $200.00 $60.00 $40.00 $60.00 $80.00 $80.00 $0.00 317194661 BIPAP CPAP SUBSQ $321.00 94662 410 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $160.50 $48.15 $32.10 $48.15 $64.20 $64.20 $0.00 317194664 UPDRAFT INITIAL/MGT $100.00 94664 412 1/6/2022 zzLRMH_CC_Respiratory $0.00 $0.00 $50.00 $15.00 $10.00 $15.00 $20.00 $20.00 $0.00 317194665 UPDRAFT/SUB $64.00 94640 412 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $32.00 $9.60 $6.40 $9.60 $12.80 $12.80 $0.00 317194667 CPT W/PERCUSSION INITIAL MGT $81.00 94667 410 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $40.50 $12.15 $8.10 $12.15 $16.20 $16.20 $0.00 317194668 CPT W/PERCUSSION $81.00 94668 410 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $40.50 $12.15 $8.10 $12.15 $16.20 $16.20 $0.00 317194760 PULSE OXIMETERY $70.00 94760 460 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $35.00 $10.50 $7.00 $10.50 $14.00 $14.00 $0.00 317194799 O2 PER HOUR $19.00 270 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $9.50 $2.85 $1.90 $2.85 $3.80 $3.80 $0.00 317294060 PFT PRE/POST SPIROMETRY $500.00 94060 460 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $250.00 $75.00 $50.00 $75.00 $100.00 $100.00 $0.00 317294377 PFT FLOW VOLUME LOOP $355.00 94375 460 7/1/2019 zzLRMH_CC_Respiratory $0.00 $0.00 $177.50 $53.25 $35.50 $53.25 $71.00 $71.00 $0.00 429493005 EKG $134.00 93005 730 7/1/2018 zzLRMH_CC_Respiratory $0.00 $0.00 $67.00 $20.10 $13.40 $20.10 $26.80 $26.80 $0.00 32795810 SLEEP STUDY BASE LINE FULLY ATTENDED "$2,450.00" 95810 920 7/1/2018 zzLRMH_CC_Sleep Lab $0.00 $0.00 "$1,225.00" $367.50 $245.00 $367.50 $490.00 $490.00 $0.00 32795811 SLEEP STUDY W/CPAP "$2,650.00" 95811 920 7/1/2018 zzLRMH_CC_Sleep Lab $0.00 $0.00 "$1,325.00" $397.50 $265.00 $397.50 $530.00 $530.00 $0.00 327958111 SLEEP STUDY CPAP TITRATION "$2,650.00" 95811 920 7/1/2018 zzLRMH_CC_Sleep Lab $0.00 $0.00 "$1,325.00" $397.50 $265.00 $397.50 $530.00 $530.00 $0.00 40398986 "SWALLOWING FUNCTIONAL LIMITATION, CURRENT STATUS" $1.00 G8986 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40398996 SWALLOW CURRENT STATUS $1.00 G8996 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40398997 SWALLOW GOAL STATUS $1.00 G8997 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40398998 SWALLOW D/C STATUS $1.00 G8998 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40398999 SPEECH FUNCTIONAL LIMITATION CURRENT STATUS $1.00 G8999 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399158 SPEECH FUNCTIONAL LIMITATION DISCHARGE STTUS $1.00 G9158 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399159 LANG. COMP. CURRENT STATUS $1.00 G9159 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399160 "LANG, COMP. GOAL STATUS" $1.00 G9160 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399162 LANG. EXPRESS CURRENT STATUS $1.00 G9162 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399163 LANG. EXPRESS GOAL STATUS $1.00 G9163 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399164 LANG. EXPRESS D/C STATUS $1.00 G9164 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399168 MEMORY CURRENT STATUS $1.00 G9168 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399169 MEMORY GOAL STATUS $1.00 G9169 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399170 MEMORY D/C STATUS $1.00 G9170 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399171 "VOICE FUNCTIONAL LIMITATION, CURRENT STATUS" $1.00 G9171 420 12/1/2017 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399172 "VOICE FUNCTIONAL LIMITATION, GOAL STATUS" $1.00 G9172 440 10/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 40399173 "VOICE FUNCTIONAL LIMITATION, DISCHARGE STATUS" $1.00 G9173 420 12/1/2017 zzLRMH_CC_Speech $0.00 $0.00 $0.50 $0.15 $0.10 $0.15 $0.20 $0.20 $0.00 403992506 SLP EVALUATION $385.00 92523 444 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $192.50 $57.75 $38.50 $57.75 $77.00 $77.00 $0.00 403992507 INDIVIDUAL THERAPY $113.00 92507 441 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $56.50 $16.95 $11.30 $16.95 $22.60 $22.60 $0.00 403992523 SPEECH EVALUATION $385.00 92523 444 1/1/2014 zzLRMH_CC_Speech $0.00 $0.00 $192.50 $57.75 $38.50 $57.75 $77.00 $77.00 $0.00 403992525 SPEECH DYSPHAGIA EVAL $120.00 92610 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $60.00 $18.00 $12.00 $18.00 $24.00 $24.00 $0.00 403992526 TX OF SWALLOW DYSFUCTION $120.00 92526 441 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $60.00 $18.00 $12.00 $18.00 $24.00 $24.00 $0.00 403992610 B/S SWALLOW EVALUATION $172.00 92610 444 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $86.00 $25.80 $17.20 $25.80 $34.40 $34.40 $0.00 403996125 COGNITIVE TEST $117.00 96125 441 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $58.50 $17.55 $11.70 $17.55 $23.40 $23.40 $0.00 403997127 COGNITIVE FUNTION $68.00 97127 440 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $34.00 $10.20 $6.80 $10.20 $13.60 $13.60 $0.00 4039S9152 SPEECH RE-EVALUATION $150.00 S9152 444 7/1/2018 zzLRMH_CC_Speech $0.00 $0.00 $75.00 $22.50 $15.00 $22.50 $30.00 $30.00 $0.00 301210 SWING BED ROOM AND BOARD $570.00 120 7/1/2018 zzLRMH_CC_Swing Bed $0.00 $0.00 $285.00 $85.50 $57.00 $85.50 $114.00 $114.00 $0.00 4042620 ABDOMEN COMPLETE - ULTRA SOUND $480.00 76700 402 7/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $240.00 $72.00 $48.00 $72.00 $96.00 $96.00 $0.00 4042630 US SINGLE ORGAN $423.00 76705 402 7/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $211.50 $63.45 $42.30 $63.45 $84.60 $84.60 $0.00 4042631 "US, LOWER EXTREMITY" $430.00 76882 402 11/1/2019 zzLRMH_CC_Ultrasound $0.00 $0.00 $215.00 $64.50 $43.00 $64.50 $86.00 $86.00 $0.00 4042640 US UPPER EXTREMITY $430.00 76881 402 7/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $215.00 $64.50 $43.00 $64.50 $86.00 $86.00 $0.00 4042690 US PELVIS COMPLETE $383.00 76856 402 7/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $191.50 $57.45 $38.30 $57.45 $76.60 $76.60 $0.00 40426306 "ULTRASOUND, CHEST" $480.00 76604 402 10/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $240.00 $72.00 $48.00 $72.00 $96.00 $96.00 $0.00 404276536 US HEAD AND NECK $546.00 76536 402 7/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $273.00 $81.90 $54.60 $81.90 $109.20 $109.20 $0.00 404276706 US ABDOMINAL AORTA $423.00 76706 402 8/1/2019 zzLRMH_CC_Ultrasound $0.00 $0.00 $211.50 $63.45 $42.30 $63.45 $84.60 $84.60 $0.00 404276830 US PELVIS W/TRANSVAGINAL $400.00 76830 402 7/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $200.00 $60.00 $40.00 $60.00 $80.00 $80.00 $0.00 404276857 US ABD/PEL LIMITED $268.00 76857 402 9/22/2020 zzLRMH_CC_Ultrasound $0.00 $0.00 $134.00 $40.20 $26.80 $40.20 $53.60 $53.60 $0.00 404276870 US SCROTUM / TESTICLES $425.00 76870 402 7/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $212.50 $63.75 $42.50 $63.75 $85.00 $85.00 $0.00 404276871 US MISCELLANEOUS $425.00 76999 402 7/1/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $212.50 $63.75 $42.50 $63.75 $85.00 $85.00 $0.00 404278013 THYROID IMAGING W/ COLOR FLOW $366.00 78013 340 7/1/2020 zzLRMH_CC_Ultrasound $0.00 $0.00 $183.00 $54.90 $36.60 $54.90 $73.20 $73.20 $0.00 404293976 CHEST ABDOMEN PELVIS COLOR FLOW $436.00 93976 921 11/7/2018 zzLRMH_CC_Ultrasound $0.00 $0.00 $218.00 $65.40 $43.60 $65.40 $87.20 $87.20 $0.00 461211045 DEB SUBC TISS EA ADD 20 SQ CM $998.00 11045 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461229580 APPLICATION UNNA BOOT RT $998.00 29580 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461281045 NEW PATIENT LEVEL 1 $350.00 99201 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $175.00 $52.50 $35.00 $52.50 $70.00 $70.00 $0.00 461281046 NEW PATIENT VISIT LEVEL 2 $350.00 99202 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $175.00 $52.50 $35.00 $52.50 $70.00 $70.00 $0.00 461281047 NEW PATIENT VISIT LEVEL 3 $403.00 99203 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $201.50 $60.45 $40.30 $60.45 $80.60 $80.60 $0.00 461281048 NEW PATIENT VISIT LEVEL 4 $585.00 99204 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $292.50 $87.75 $58.50 $87.75 $117.00 $117.00 $0.00 461281050 ESTABLISHED PAT VISIT LEVEL 1 $350.00 99211 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $175.00 $52.50 $35.00 $52.50 $70.00 $70.00 $0.00 461281051 ESTABLISHED PAT VISIT LEVEL 2 $350.00 99212 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $175.00 $52.50 $35.00 $52.50 $70.00 $70.00 $0.00 461281052 ESTABLISHED PAT VISIT LEVEL 3 $403.00 99213 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $201.50 $60.45 $40.30 $60.45 $80.60 $80.60 $0.00 461281053 ESTABLISHED PAT VISIT LEVEL4 $585.00 99214 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $292.50 $87.75 $58.50 $87.75 $117.00 $117.00 $0.00 461297597 DEBRIDE DEVIT.TISSUE FS 20CM $998.00 97597 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461297598 DEBRIDE DEVIT TISSUE E AD 20CM $998.00 97598 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461297602 ACTIVE WOUND MGMT NON SELECTIV $998.00 97602 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461299117 APP ML VENOUS WOUND COMPRESS $998.00 29581 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461299325 "DEBRIDE,BONE 1ST 20CM" "$2,679.00" 11044 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 "$1,339.50" $401.85 $267.90 $401.85 $535.80 $535.80 $0.00 461299326 DEB SUBCUT TISS EA ADD 20 SQCM $998.00 11045 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461299327 DEB MUSCLE EA ADD 20 SQ CM $998.00 11046 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461299338 DEBRIDE MUSCLE/FASCIA 1ST 20CM $998.00 11043 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00 461299339 DEBRIDE MUSCLE/FASC EA ADD20CM $998.00 11046 510 7/1/2018 zzLRMH_CC_Wound Care $0.00 $0.00 $499.00 $149.70 $99.80 $149.70 $199.60 $199.60 $0.00